Skip to main content

Evidence-based policy making for health promotion to reduce the burden of non-communicable diseases in Moldova

Abstract

The Republic of Moldova faces several concurrent health challenges most notably an increase in chronic non-communicable diseases, spiralling health care costs and widening health inequalities. To accelerate progress in their resolution there is a need for new and innovative health promotion and behaviour change communication interventions. The Ministry of Health, Labour and Social Protection in collaboration with the newly created National Agency for Public Health held a conference on the occasion of the Moldovan National Day of Health Promotion on 14th March 2018 in which national and invited international experts exchanged their views on (1) best practice examples of behaviour change interventions, health promotion activities and lessons learned from the UK and elsewhere; and (2) possible ways forward for Moldova to implement cost-effective and evidence-based intersectoral health promotion programmes. The experts provided recommendations on implementing behaviour change interventions to reduce and prevent obesity; on the creation of a favourable tobacco control environment to reduce smoking prevalence; and on how physical activity programme design can benefit from health psychology research. All these strategies could foster health promotion activities and ultimately contribute to improving the health outcomes of the Moldovan population.

Background

Epidemiological transition and non-communicable diseases in Moldova

Non-communicable diseases (NCDs) accounted for about 70% of all deaths globally in 2015 and more than 80% of these premature deaths were in low-income and middle-income countries (LMICs) [1]. Like many countries, the Republic of Moldova (hereinafter Moldova) faces a recent transition in the profile of health affecting the health status of its population with a growing NCD burden [2]. The prevalence of NCDs in the country is very high, accounting for 90% of all-cause mortality in 2016. The major NCDs are cardiovascular diseases (CVDs) and cancers, accounting for 59 and 15% of all deaths, respectively [3].

Alcohol consumption and tobacco smoking are the key health risks for most Moldovans and mortality and morbidity from these risk factors account for a sizeable disease burden on society [3]. According to 2010 figures, 58% of total male mortality and 62% of female mortality could be attributed to smoking-related causes, while 19% of male mortality and 14% of female mortality were related to alcohol consumption [4, 5]. There is an uneven distribution of the major risk factors with men having higher rates of engaging in tobacco smoking and alcohol consumption (Table 1) [3, 6, 7]. As shown in Table 1, overweight and obesity constitutes another major public health problem in Moldova with 47% of its adult population (18 and over) being classified as overweight or obese (BMI ≥ 25) in 2014 [7]. Current physical activity levels in Moldova are unclear [8], with 2013 data suggesting 10% of the population is insufficiently active while 76% does not engage in vigorous activity [9]. Physical inactivity however is one of 10 leading behavioural risk factors contributing to disease burden in Moldova [8]. High systolic blood pressure is the second contributor to burden of disease in Moldova after dietary risks [8].

Table 1 Major risk factors among the Moldovan population

However, these estimates show that there is a lack of more recent, aggregated, data on the burden of NCDs and associated risk factors amongst the Moldovan population [2, 3, 6, 7]. The existing system for NCD surveillance is not operational, and data on risk factors and behaviours related to NCDs are not routinely collected as part of the country’s health information system [3].

NCD and health promotion policy environment in Moldova

The Government of Moldova has embarked on a health system reform to primarily strengthen the delivery and quality of primary health care since the late 1990s [4]. Moldova made considerable advances in reorienting its hospital-focused health system towards primary healthcare (PHC) based on a family medicine model where private health providers are directly contracted by the health insurance system [4]. The health insurance, however, inadequately covers costs for both the provider and the patient with high out-of-pocket costs for medicines, and thus limits patients’ access to critical therapies and care, especially for chronic illnesses [2, 10]. Moreover, there are few state-supported health promotion activities sustained by the PHC system and family doctors continue to be largely focused on the provision of curative services, whilst public health promotion and prevention activities are considered to be of a lesser concern in resource-constrained circumstances. This is also exemplified by the proportion of public health expenditures from 2010, which is high for curative services (68%) and very low for public health and prevention (5%) [4].

The Ministry of Health, Labour and Social Protection (MoHLSP) has made progress in establishing an extensive legal and policy framework relevant to the control and improvement of service delivery for NCDs. NCDs have gained high priority in two overarching national policy frameworks for health; the Moldovan National Health Policy for 2007–2021 [11], and the Health Care System Development Strategy for 2008–2017 [12]. Both pursue the goal of significantly reducing the NCD disease burden and avoiding premature deaths through integrated actions, improving the quality of life and healthy life expectancy [2]. In line with national policy commitments, the Parliament has approved a NCD Prevention and Control Strategy 2012–2020 in 2012 [13]. The core focus of this strategy is the control of the main NCDs and their risk factors, as well as opportunities to prevent them. At the same time, it has launched several national programmes related to alcohol and tobacco control to address major risk factors for NCDs [2]. A national Health Promotion Programme encourages healthy behaviours at all stages of life through the modification of attitudes and improvement of knowledge among adults, adolescents and youth. Capacity building of health and education specialists on planning and implementing health promotion actions at national and local level are at the core of this Programme. However, even though NCDs gained political momentum, progress in implementing national chronic disease programmes and strategies has been slow with limited financial resources for implementation [2]. The burden of NCDs and related health care costs still undermine social and economic development in Moldova and represent an urgent public health priority [14].

The healthy life project “Reducing the Burden of NCDs in Moldova”

The Swiss Agency for Development and Cooperation’s (SDC) Healthy Life Project was launched in 2017 to support the MoHLSP in reducing the burden of NCDs in Moldova as part of a bilateral development aid agreement. The Healthy Life Project is implemented by the Swiss Tropical and Public Health Institute (Swiss TPH) and its national and local partners, i.e. the raion (district) and local public authorities, medical teaching and training institutes for family health, primary health care and public health services, and community-based organisations. The project is designed to support the development of an enabling policy environment, to improve the quality uptake of NCD services at PHC level, and to increase the healthcare seeking behaviour of the population [15].

On the occasion of the Moldovan National Day of Health Promotion specialist on 14th March 2018, a two-day working conference was organised by the MoHLSP and the newly created National Agency for Public Health in Chisinau. The aim of this conference was to share the latest evidence in health promotion and behaviour change for NCDs by international and national experts in an interactive workshop setting. The objective of the workshop was to develop action plans for behaviour change interventions by multisectoral raion teams, taking into account latest scientific evidence and international best practice examples. To this end, the conference organisers invited international health promotion, behaviour change and health psychology experts from their professional networks, national public health policy experts and practitioners, representatives from medical, social, educational sectors, community leaders and local public authorities as well as the representatives from the MoHLSP to participate as speakers and panellists. As the conference aimed at many non-English speaking health professionals facing a language barrier in their access to research literature, the conference was being translated into Romanian and Russian in real time alongside the slides. As an outcome of the conference, this paper specifically describes:

  1. (1)

    best practice examples of behaviour change interventions, health promotion activities and lessons learned from the UK on the topics of physical activity, obesity and tobacco cessation (explained by three international conference speakers)

  2. (2)

    recommendations for Moldova on how to adapt some of these health promotion strategies to its context to improve the health status of the Moldovan population.

We begin our summary of the conference with three best practice examples of health promotion and behaviour change interventions in the U.K. in the areas of overweight and obesity guidelines development, tobacco cessation and physical activity. We will then highlight recommendations from the speakers for guiding the development of behaviour change strategies in Moldova adapted to the national context and resources for a successful promotion of healthy lifestyles.

Case study 1: developing national guidance for effective diet and obesity interventions

Overweight and obesity are increasingly affecting the population of the UK; the prevalence of obesity rose from 6% of men and 8% of women in 1980 to 26% of men and 27% of women in 2016 [16, 17]. Overweight is more common than obesity among the UK population, with 40% of men and 30% of women classified as overweight in 2016 [17]. The illnesses related to an excess of weight include type 2 diabetes, hypertension, stroke, dyslipidaemia, osteoarthritis and some cancers [18, 19]. The treatment of obesity remains challenging and requires multicomponent weight management programmes, but up to 2014, existing service provision was often limited in scope [20, 21].

It is now widely recognised that multiple interventions at multiple levels are often needed to initiate and sustain behaviour change effectively. Interventions on social and behavioural factors related to health should link multiple levels of influence, including the individual, interpersonal, institutional, community, and policy levels [22]. Public health interventions should not only be targeted at individuals, but also affect interpersonal, organisational, and environmental factors influencing health behaviour as it is increasingly recognised that individual behaviour change affects and is affected by the larger socioecological environment [23, 24]. There is increasing emphasis on identifying evidence-based interventions and disseminating them widely [25]. One of these examples is the development of evidence-based national guidance and advice by the National Institute for Health and Care Excellence (NICE).

Development of a national guidance on overweight and obesity prevention and management

Since 1999 NICE has been developing recommendations on public health interventions in the UK using the best available evidence for disease prevention and control for those working in health and social care in England [26]. The role of NICE is to improve outcomes for people using the National Health Service (NHS) and other public health and social care services. NICE pursues an evidence-based approach to produce guidance and advice for health, public health, and social care practitioners. It has produced a number of guidelines on diet management, behaviour change and physical activity that make recommendations on local interventions to help prevent disease or improve health [26], such as its guidance on managing overweight and obesity.

In 2014, NICE has up-dated its evidence-based guidance on obesity and weight management [27], obesity prevention [27], as well as on lifestyle services for overweight or obese adults [28]. As summarised in Table 2, this guidance outlines how public health services and local authorities can increase physical activity levels in a variety of settings (early childhood development settings, schools and workplaces) and achieve dietary changes among their target populations. It covers the core component for effective lifestyle weight management services and recommends an integrated approach to preventing and managing obesity. Moreover, it also addresses community-wide strategies to prevent obesity through the sustainable engagement of local communities, local organisations, and networks.

Table 2 Overview of behaviour change interventions covered by the different guidance on obesity

Examples of how the guidance has been put into practice and evaluated in the NHS, local authorities, voluntary sector and a range of other organisations can be found on the NICE shared learning pages [29, 30].

Case study 2: effective behaviour change interventions for smoking cessation and prevention

Smoking remains the largest, preventable cause of death worldwide, killing more than 7 million people around the world each year, of them 114,513 per year in the UK [31]. Tobacco use is highly addictive, resulting in only half of smokers managing to quit tobacco completely in their lifetime [32]. Not only does smoking have dire health consequences - smokers die on average at least 10 years earlier than non-smokers [33, 34] - but it also causes high health costs and loss of productivity [35]. Reducing tobacco consumption is therefore likely not only going to improve the health but also the wealth of a nation [36].

There are several frameworks that help in the development, evaluation and categorisation of tobacco control interventions. One of them is the conceptualisation of tobacco control methods into their mode of action and level of delivery which work at different stages of the tobacco epidemic [37].

At the earliest stage of the epidemic, increasing awareness in the population of the consequences of tobacco use through mass media campaigns showed positive results [38]. At the same time, publicising basic research likely increases awareness and can change behaviour not only of smokers themselves but also of health professionals to support tobacco control [39]. Lastly, changing social norms and values can create a favourable atmosphere for tobacco control [40].

Taxation is one of the most effective ways to reduce tobacco consumption and is often introduced at later stages in the epidemic [41]. The introduction of clean air laws and smoking bans can have a similar impact on tobacco use as tax increases [42]. Finally, product regulation can help make cigarettes less addictive and therefore less attractive and can help encourage smokers to switch to less dangerous products to reduce harm [43, 44].

At the latter stages of the tobacco epidemic, intervention programmes operating at the individual level tend to be implemented. They usually mobilise a combination of approaches ranging from behavioural support interventions (such as brief counselling, telephone counselling or intensive face-to-face support) to e-health approaches (text messaging, internet and apps) and pharmacotherapy (nicotine replacement therapy and Varenicline). Table 3 further elaborates on the range of effective behaviour change interventions for tobacco cessation and prevention which are available for policy-makers and intervention designers.

Table 3 Overview of behaviour change interventions for tobacco cessation and prevention

In general, successful behaviour change interventions for smoking cessation and prevention are among the cost-effective healthcare interventions [60, 61]. However, there is a trade-off insofar as cheaper, less intensive interventions have a lower impact than more expensive, intensive interventions but the latter may be less affordable for LMICs [62]. Overall, it is the combination of pharmacotherapy with behavioural support which provides the best long-term outcomes for smoking cessation.

Case study 3: designing an effective community-based physical activity programme for those with CVD risk and poor mental health

Physical activity is one of the most underused behavioural medicines, with 40% of adults in the UK [63], 45% in Australia [64], and 79% in America [65], failing to reach the World Health Organization (WHO) recommendations of 150 min of moderate to vigorous physical activity per week [66]. In addition to these recommendations, it is important to break up sitting time in order to reduce the risk of non-communicable disease [67]. Physical inactivity is the fourth leading risk factor for mortality, accounting for 6% of deaths worldwide [66]. Hence, the practise of regular physical activity has huge potential to reduce all-cause mortality and enhance good health [68, 69], protecting against and benefiting the treatment of CVDs [70], stroke, cancer, type 2 diabetes [71], and depression [72]. Public health programmes that aim to enhance physical activity are therefore of priority.

In order to enable a global understanding of what works to enhance physical activity and target NCDs, it is argued that: 1) behavioural science and public health must work together and 2) effective interventions are not developed ‘by chance’, instead the intervention design, delivery, evaluation and adoption must draw upon relevant strategies, frameworks and approaches to perform and address a systematic behavioural diagnosis of the target population [73,74,75].

The community-based health programme ‘Active Herts’ aimed to enhance physical activity, health and wellbeing in those with CVD risk and poor mental health [76]. It was informed by the Behaviour Change Wheel (BCW) and COM-B model of behaviour [77], and the latest evidence from health psychology using this model to explain physical activity [78]. Table 4 provides an overview of some of the core determinants that were targeted based on a COM-B behavioural diagnosis.

Table 4 COM-B diagnosis of factors that influence participation in physical activity

To ensure scientific rigour and long-term effectiveness, the programme drew from a systematic review of the literature that highlighted successful strategies for physical activity enhancement and/or sedentary behaviour reduction [79, 80]. Table 5 shows the behaviour change techniques (BCTs) drawn from the 93 item taxonomy that were found to be effective at changing physical activity behaviour from the review of published evidence [81].

Table 5 Behaviour change techniques (BCTs) frequently found to be applied in effective physical activity interventions

Based on these findings, the ‘Active Herts’ programme was designed to include the BCTs shown to be the most effective at enhancing physical activity, alongside others that target Capability, Opportunity and Motivation (COM-B). The programme consisted of a 45 min one-to-one consultation and a phone call booster (2 weeks later) with a Registered Exercise Professional (Get Active Specialist: GAS) who had been specifically trained in behaviour change, motivational interviewing and health coaching [75, 82]. The GAS supported programme users through the consultation, using an Active Herts booklet (focusing on BCTs such as goal setting, problem solving, action planning, prompts/cues, self-reward, social support), and then referred them to local exercise classes (instruction on how to perform the behaviour, demonstration of the behaviour, behaviour practice/rehearsal), that were free in two of the four programme areas. To support replicability, a protocol was published and made open access [76]. Early evaluation results show that there was a significant increase in the number of programme users who reported engaging in regular physical activity 12 months after the intervention, alongside improved health and wellbeing levels [75].

Physical activity bears great potential for maintaining health and treating illness. Applying behavioural science in public health settings to understand and change behaviour can maximise the scale of the impact of public health interventions and assist in the mission to improve world-wide population health and wellbeing.

Discussions and recommendations for Moldova – adopting evidence-based approaches to health promotion

The final session of the conference was dedicated to discussing and identifying potential strategies to effectively implement behaviour change interventions and health promotion activities within primary health care settings at the raion level in Moldova. The following key recommendations resulted from this discussion and the experts interventions.

Prioritize cost-effective and evidence-based interventions to reduce and prevent obesity

Moldova should consider implementing cost-effective and evidence-based interventions to reduce the high prevalence of obesity. Prevention of obesity through lifestyle weight management programmes delivered by skilled providers is an option. NICE provides recommendations on the core components for effective weight loss and Moldova should consider implementing some of these measures in a coordinated way through multidisciplinary providers [81]. Given the limited resources available within Moldova, when considering implementing behaviour change interventions to reduce obesity it is worthwhile to remember that potential additional costs may be incurred when training staff, including those not directly involved in services providing behaviour change interventions. Costs can also be incurred when evaluating and monitoring behaviour change interventions. However, interventions aimed at changing people’s health-related behaviours have the potential to improve their health and wellbeing considerably and any costs can be offset by disinvesting in interventions where evidence shows them to be not effective or harmful. These savings could be reinvested in effective evidence-based services.

Create a favourable tobacco control environment to reduce smoking prevalence

Moldova should consider increased taxation for tobacco products to drive down smoking prevalence. Existing social norms around gender-specific smoking rates should be exploited to create a favourable tobacco control environment. Further mass media campaigns may be useful, but only if there is evidence of low awareness of the consequences of tobacco use in the general population.

Primary physicians have a key role in helping people to stop smoking through brief counselling (see Table 3). Increasing the number of General Practitioners providing smoking cessation advice is likely to have an impact at population level and is cheap (around US$19). These cost estimates were derived from the Affordability Calculator [83], whereby Moldova specific data on GDP were used with additional reference data based on Russian estimates. Furthermore, the rise in the popularity of e-cigarettes has provided the opportunity for a consumer-driven intervention which may reduce smoking rates via harm reduction [83]. E-cigarettes can become cheaper than cigarettes (around US$20–25) and as this approach is self-funded it would be free to governments. Nicotine replacement therapy with cytisine which is similar in action to varenicline can be just as effective but is much cheaper (US$20) [62, 77, 84]. The Law on tobacco control was amended by the Parliament of Moldova in July 2019 towards increased regulation of non-burning tobacco products, in line with the position of WHO recognizing that electronic nicotine delivery systems (ENDS) are not harmless and the evidence of the impact on health remains limited [85]. Whether or not e-cigarettes should be used in the framework of a harm reduction approach is currently debated [86, 87].

Furthermore, text-based interventions are cheap (around US$39) and can have a wide reach (see Table 3). They are therefore ideal in the context of Moldova. However, the usefulness of text-based interventions partly depends on the extent of skilled mobile phone use in specific population groups such as the elderly, and the quality of existing networks, especially in remote areas.

Similarly, tailored self-help material is cheap (around US$10–14) and has similar effectiveness to brief advice [88]. This is also true for telephone quit lines which are cost-effective and can reach large sways of the population. Lastly, while more evidence needs to accumulate for internet and app-based smoking cessation interventions, their wide reach and low cost makes them an ideal candidate for inclusion in comprehensive treatment packages for LMICs such as Moldova. Because developments in this area are rapid, these tools should be closely monitored as evidence is increasing to support their effectiveness, and they may be particularly suitable for targeting younger or more disadvantaged smokers [89, 90].

Design and implement evidence-based, community programmes on physical activity

In Moldova there is a need to develop and maintain national guidelines and surveillance for levels of physical activity in the general population [91]. This is essential to assess current needs for increased intervention and design adapted behaviour change programmes to support a beneficial change in behaviour. Furthermore, physical activity intervention or programme developers should consider evidence-based frameworks, theoretical approaches and insights from health psychology and behavioural science to guide intervention design, development, delivery, evaluation and adoption strategies (IDDEAS: [92, 93]). Community-based programmes jointly implemented by skilled providers across all sectors, with targeted individual behavioural support, should be the preferred level of intervention, especially in lower-income settings to avoid a waste in resource. A detailed protocol developed that explains what the intervention aims to do, how it will do it and why can aid in replication and roll-out if the programme is successful. Following the Active Herts protocol could support the development of future interventions in this area using the evidence-based and theoretically-driven behaviour change techniques and approaches mentioned above [76] and further research into local health behaviour determinants in targeted population groups in Moldova are encouraged to use this approach.

Conclusions

The case studies shown during the Conference described here provide a number of best practice interventions adaptable to Moldova, including options for resource-constrained settings. Health psychology research can inform the development of appropriate individual and population health promoting strategies but access by Moldovan specialists to this body of scientific evidence requires sustained support and investment. Overall, there is growing awareness of the complexities of embedding behavioural science in public health practice more widely [94]. It will be important that health promotion strategy development benefit from extensive and appropriately funded stakeholder consultations to ensure the inclusion of the latest evidence.

The implementation of cost-effective and evidence-based interventions to reduce obesity, the creation of a favourable tobacco control environment to reduce the smoking prevalence and the design of community-based programmes for physical activity is expected to foster national behaviour change communication and health promotion activities and in a longer-term, contribute to strengthening the national health system and improve the health outcomes of the Moldovan population [95, 96].

Availability of data and materials

Not applicable.

Abbreviations

BCTs:

Behaviour change techniques

BCW:

Behaviour change wheel

BMI:

Body mass index

COM-B:

Capability, opportunity and motivation

CVDs:

Cardiovascular diseases

ENDS:

Electronic nicotine delivery systems

GAS:

Get Active Specialist

IDDEAS:

Intervention design, development, delivery, evaluation and adoption strategies

JSNA:

Joint strategic needs assessment

LMICs:

Low-income and middle-income countries

MoHLSP:

Ministry of health, labour and social protection

NCDs:

Non-communicable diseases

NHS:

National health service

NICE:

National Institute for Health and Care Excellence

PHC:

Primary healthcare

SDC:

Swiss Agency for Development and Cooperation

Swiss TPH:

Swiss Tropical and Public Health Institute

UK:

United Kingdom

WHO:

World Health Organization

References

  1. 1.

    WHO: Global Health Observatory Data. NCD mortality and morbidity. [http://www.who.int/gho/ncd/mortality_morbidity/en/], accessed: [April 10, 2019].

  2. 2.

    Skarphedinsdottir M, Smith B, Ferrario A, Zues O, Ciobanu A, Tirdea M, Domente S, Habicht J. Better noncommunicable disease outcomes: challenges and opportunities for health systems: Republic of Moldova country assessment. World Health Organization Regional Office for Europe: Copenhagen; 2014.

    Google Scholar 

  3. 3.

    WHO. Noncommunicable diseases country profiles. Republic of Moldova; 2018. [https://www.who.int/nmh/countries/mda_en.pdf?ua=1], accessed: [April 10, 2019]

  4. 4.

    Turcanu G, Domente S, Buga M, Richardson E. Republic of Moldova: health system review. Health Syst Transit. 2012;14:1–151.

    PubMed  Google Scholar 

  5. 5.

    WHO. Evaluation of the structure and provision of primary care in the Republic of Moldova. Copenhagen: WHO Regional Office for Europe; 2012.

    Google Scholar 

  6. 6.

    Ministry of Health. National Strategy on Public Health for years 2014-2020, approved by the Governmental Decision nr. 1032 from 20 December 2013 and published in Monitorul Oficial N 304-310 on 27 December 2013.

  7. 7.

    WHO: Republic of Moldova. Highlights on health and well-being. Copenhagen: WHO Regional Office for Europe; 2016.

    Google Scholar 

  8. 8.

    WHO: Republic of Moldova: profile of health and well-being. [http://www.euro.who.int/__data/assets/pdf_file/0005/323258/Profile-health-well-being-Rep-Moldova.pdf?ua=1], accessed: [April 10, 2019].

  9. 9.

    WHO. Prevalence of non-communicable disease risk factors in the Republic of Moldova - STEPS 2013. Copenhagen: WHO Regional Office for Europe; 2014.

    Google Scholar 

  10. 10.

    Vian T, Feeley FG, Domente S, Negruta A, Matei A, Habicht J. Barriers to universal health coverage in Republic of Moldova: a policy analysis of formal and informal out-of-pocket payments. BMC Health Serv Res. 2015;15:319.

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Government of the Republic of Moldova: Decision no 886 from 06.08.2007 regarding Approval of the National Health Policy Monitorul Oficial no 127–130, art. 931 [http://lex.justice.md/md/324940/], accessed: [April 10, 2019].

  12. 12.

    Government of the Republic of Moldova: Decision no 1471 from 24.12.2007 regarding Approval of the National Healthcare Strategy for the years 2008–2017. Monitorul Oficial 8–10, art 43. [http://lex.justice.md/md/326615/], accessed: [April 10, 2019].

  13. 13.

    Parliament of the Republic of Moldova: Decision no 182 from 12.04.2012 regarding Approval of National Strategy of Prevention and Control of Non-Communicable Diseases for the years 2012–2020. Monitorul Oficial no 126–129, art 412. [http://lex.justice.md/viewdoc.php?action=view&view=doc&id=343682&lang=1], accessed: [April 10, 2019].

  14. 14.

    Hone T, Habicht J, Domente S, Atun R. Expansion of health insurance in Moldova and associated improvements in access and reductions in direct payments. J Glob Health. 2016;6:020702.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Swiss TPH Healthy Life Project - Reducing the burden of non-communicable diseases in Moldova. [https://www.swisstph.ch/en/projects/project-detail/project/healthy-life-project-reducing-the-burden-of-non-communicable-diseases-in-moldova/], accessed: [April 10, 2019].

  16. 16.

    Rennie KL, Jebb SA. Prevalence of obesity in Great Britain. Obes Rev. 2005;6:11–2.

    Article  CAS  Google Scholar 

  17. 17.

    Health and Social Care Information Centre: Health survey for England, 2016. [https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/health-survey-for-england-2016], accessed: [April 10, 2019].

    Google Scholar 

  18. 18.

    Burton B, Foster W, Hirsch J, Van TI. Health implications of obesity: an NIH consensus development conference. Int J Obes. 1985;9:155–70.

    CAS  PubMed  Google Scholar 

  19. 19.

    Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. Jama. 1999;282:1523–9.

    Article  CAS  Google Scholar 

  20. 20.

    NHS England: Joined up clinical pathways for obesity: Report of the working group. [https://www.england.nhs.uk/wp-content/uploads/2014/03/owg-join-clinc-path.pdf], accessed: [April 10, 2019].

  21. 21.

    Stegenga H, Haines A, Jones K, Wilding J. Identification, assessment, and management of overweight and obesity: summary of updated NICE guidance. BMJ. 2014;349:g6608.

    Article  Google Scholar 

  22. 22.

    Syme SL, Smedley BD. Promoting health: intervention strategies from social and behavioral research. Washington, DC: National Academies Press; 2000.

    Google Scholar 

  23. 23.

    NICE. Behaviour change at population, community and individual levels [NICE public health guidance 6]. London: National Institute for Health and Care Excellence; 2007.

    Google Scholar 

  24. 24.

    Davis R, Campbell R, Hildon Z, Hobbs L, Michie S. Theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review. Health Psychol Rev. 2015;9:323–44.

    Article  Google Scholar 

  25. 25.

    Glanz K, Rimer BK, Viswanath K. Health behavior and health education: theory, research, and practice. San Francisco, CA: Wiley; 2008.

    Google Scholar 

  26. 26.

    NICE: What we do. [https://www.nice.org.uk/about/what-we-do], accessed: [April 10, 2019].

  27. 27.

    NICE: Obesity: identification, assessment and management. Clinical guideline [CG189]. [https://www.nice.org.uk/guidance/cg43], accessed: [April 10, 2019].

  28. 28.

    NICE: Obesity prevention. Clinical guideline [CG43]. [https://www.nice.org.uk/guidance/cg43], accessed: [April 10, 2019].

  29. 29.

    NICE: Choose to change service delivered by ABL Health (ABL): Adults about to complete a lifestyle weight management programme agree a plan to prevent weight regain. [https://www.nice.org.uk/sharedlearning/choose-to-change-service-delivered-by-abl-health-abl-adults-about-to-complete-a-lifestyle-weight-management-programme-agree-a-plan-to-prevent-weight-regain], accessed: [April 10, 2019].

  30. 30.

    NICE: 2018 Surveillance of obesity: identification, assessment and management (2014) NICE guideline CG189. [https://www.nice.org.uk/guidance/cg189/evidence/appendix-a2-summary-of-evidence-from-surveillance-cg189-pdf-4847559663], accessed: [April 10, 2019].

  31. 31.

    World Lung Foundation/American Cancer Society: The tobacco atlas. [http://www.tobaccoatlas.org], accessed: [April 10, 2019].

  32. 32.

    WHO. Tobacco or health: a global status report. Geneva: World Health Organization; 1997.

    Google Scholar 

  33. 33.

    Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ. 2004;328:1519–28.

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Pirie K, Peto R, Reeves GK, Green J, Beral V, Million Women Study C. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet. 2013;381:133–41.

    Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    Lightwood J, Collins D, Lapsley H, Novotny TE. In: Jha P, Chaloupka F, editors. Estimating the cost of tobacco use, in Tobacco control in developing countries. Oxford: Oxford University Press; 2000. p. 63–103.

    Google Scholar 

  36. 36.

    Jha P, Chaloupka FJ. Curbing the epidemic: governments and the economics of tobacco control. Washington, DC: World Bank; 1999.

    Google Scholar 

  37. 37.

    Slama K, Control T. In: Sancho-Garnier H, et al., editors. Evidence-based cancer prevention: strategies for NGOs. Geneva, Switzerland: International Union Against Cancer; 2004. p. 74–93.

    Google Scholar 

  38. 38.

    Hopkins DP, Briss PA, Ricard CJ, Husten CG, Carande-Kulis VG, Fielding JE, Alao MO, McKenna JW, Sharp DJ, Harris JR, Woollery TA, Harris KW. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med. 2001;20:16–66.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Lundberg GD. In the AMA, policy follows science: a case history of tobacco. JAMA. 1985;253:3001–3.

    Article  CAS  Google Scholar 

  40. 40.

    Aquilino ML, Lowe JB. Approaches to tobacco control: the evidence base. Eur J Dent Educ. 2004;8:11–7.

    Article  Google Scholar 

  41. 41.

    Ranson MK, Jha P, Chaloupka FJ, Nguyen SN. Global and regional estimates of the effectiveness and cost-effectiveness of price increases and other tobacco control policies. Nicotine Tob Res. 2002;4:311–9.

    Article  Google Scholar 

  42. 42.

    Stephens T, Pederson LL, Koval JJ, Kim C. The relationship of cigarette prices and no-smoking bylaws to the prevalence of smoking in Canada. Am J Public Health. 1997;87:1519–21.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. 43.

    Henningfield JE, Benowitz NL, Slade J, Houston TP, Davis RM, Deitchman SD. Reducing the addictiveness of cigarettes. Council on scientific affairs, American medical association. Tob Control. 1998;7:281–93.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Stratton S, Shetty P, Wallace R, Bondurant S. Clearing the smoke: addressing the science base for tobacco harm reduction. Washington, DC: National Academy Press; 2001.

    Google Scholar 

  45. 45.

    Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2013;5:CD000165.

    Google Scholar 

  46. 46.

    West R, Walia A, Hyder N, Shahab L, Michie S. Behavior change techniques used by the English stop smoking services and their associations with short-term quit outcomes. Nicotine Tob Res. 2010;12:742–7.

    Article  Google Scholar 

  47. 47.

    Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev. 2017;3:CD001292.

    PubMed  Google Scholar 

  48. 48.

    Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database Syst Rev. 2005;18:CD001007.

    Google Scholar 

  49. 49.

    Free C, Knight R, Robertson S, Whittaker R, Edwards P, Zhou W, Rodgers A, Cairns J, Kenward MG, Roberts I. Smoking cessation support delivered via mobile phone text messaging (txt2stop): a single-blind, randomised trial. Lancet. 2011;378:49–55.

    Article  PubMed  PubMed Central  Google Scholar 

  50. 50.

    Whittaker R, McRobbie H, Bullen C, Borland R, Rodgers A, Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Database Syst Rev. 2012;11:CD006611.

    PubMed  Google Scholar 

  51. 51.

    Shahab L, McEwen A. Online support for smoking cessation: a systematic review of the literature. Addiction. 2009;104:1792–804.

    Article  Google Scholar 

  52. 52.

    Haskins BL, Lesperance D, Gibbons P, Boudreaux ED. A systematic review of smartphone applications for smoking cessation. Transl Behav Med. 2017;7:292–9.

    Article  PubMed  PubMed Central  Google Scholar 

  53. 53.

    West R, Shahab L, Smoking cessation interventions, in evidence-based public health, A. Killoran and M. Kelly,. 2010, Oxford University Press: Oxford.

    Google Scholar 

  54. 54.

    Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database SystRev. 2012;11:CD000146.

    Google Scholar 

  55. 55.

    Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, Lawrence D, Ascher J, Russ C, Krishen A, Evins AE. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016;387:2507–20.

    Article  CAS  Google Scholar 

  56. 56.

    Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2016;9:CD006103.

    Google Scholar 

  57. 57.

    Ferguson J, Bauld L, Chesterman J, Judge K. The English smoking treatment services: one-year outcomes. Addiction. 2005;100(Suppl 2):59–69.

    Article  Google Scholar 

  58. 58.

    Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev. 2013;5:CD009329.

    Google Scholar 

  59. 59.

    Chang PH, Chiang CH, Ho WC, Wu PZ, Tsai JS, Guo FR. Combination therapy of varenicline with nicotine replacement therapy is better than varenicline alone: a systematic review and meta-analysis of randomized controlled trials. BMC Public Health. 2015;15:689.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  60. 60.

    Shahab L. NCSCT briefing 7: cost-effectiveness of pharmacotherapy for smoking cessation. Dorchester: NHS Centre for Smoking Cessation and Training; 2011.

    Google Scholar 

  61. 61.

    Shahab L. NCSCT briefing: effectiveness and cost-effectiveness of programmes to help smokers to stop and prevent smoking uptake at local level. Dorchester: National Centre for Smoking Cessation and Training; 2015.

    Google Scholar 

  62. 62.

    West R, Raw M, McNeill A, Stead L, Aveyard P, Bitton J, Stapleton J, McRobbie H, Pokhrel S, Lester-George A, Borland R. Health-care interventions to promote and assist tobacco cessation: a review of efficacy, effectiveness and affordability for use in national guideline development. Addiction. 2015;110:1388–403.

    Article  PubMed  PubMed Central  Google Scholar 

  63. 63.

    Her Majesty's Government Department for Digital C, Media & Sport, : Sporting future: first annual report. [https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/590578/Sporting_Future_-_first_annual_report_final.pdf], accessed: [April 10, 2019].

  64. 64.

    Australian Government Department of Health: The national health survey 2014–2015. [http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-active-evidence.htm], accessed: [April 11, 2019].

  65. 65.

    Centers for Disease Control and Prevention: Facts about physical activity. [https://www.cdc.gov/physicalactivity/data/facts.htm], accessed: [April 11, 2019].

  66. 66.

    World Health Organization: Global recommendations on physical activity for health: 18–64 year olds. [http://www.who.int/dietphysicalactivity/physical-activity-recommendations-18-64years.pdf?ua=1], accessed: [April 11, 2019].

  67. 67.

    Bailey DP, Locke CD. Breaking up prolonged sitting with light-intensity walking improves postprandial glycemia, but breaking up sitting with standing does not. J Sci Med Sport. 2015;18:294–8.

    Article  Google Scholar 

  68. 68.

    Bauman AE. Updating the evidence that physical activity is good for health: an epidemiological review 2000-2003. J Sci Med Sport. 2004;7:6–19.

    Article  CAS  Google Scholar 

  69. 69.

    Lollgen H, Bockenhoff A, Knapp G. Physical activity and all-cause mortality: an updated meta-analysis with different intensity categories. Int J Sports Med. 2009;30:213–24.

    Article  CAS  Google Scholar 

  70. 70.

    Barengo NC, Antikainen R, Borodulin K, Harald K, Jousilahti P. Leisure-time physical activity reduces total and cardiovascular mortality and cardiovascular disease incidence in older adults. J Am Geriatr Soc. 2017;65:504–10.

    Article  Google Scholar 

  71. 71.

    Rhodes RE, Janssen I, Bredin SSD, Warburton DER, Bauman A. Physical activity: health impact, prevalence, correlates and interventions. Psychol Health. 2017;32:942–75.

    Article  Google Scholar 

  72. 72.

    Schuch FB, Vancampfort D, Richards J, Rosenbaum S, Ward PB, Stubbs B. Exercise as a treatment for depression: a meta-analysis adjusting for publication bias. J Psychiatr Res. 2016;77:42–51.

    Article  Google Scholar 

  73. 73.

    Chater A. HPPHN [Health Psychology in public health network]: look how far we have come in such a short time. Health Psychol Public Health. 2017;1:2–3.

    Google Scholar 

  74. 74.

    Chater A. Developing and applying translational behavioural science to improve population health and reduce inequalities. Health Psychol Public Health. 2018;2:5–7.

    Google Scholar 

  75. 75.

    Howlett N, Jones A, Chater A. Active Herts: translating behavioural science into public health. Behav Sci Public Health. 2019;1:1.

    Google Scholar 

  76. 76.

    Howlett N, Jones A, Bain L, Chater A. How effective is community physical activity promotion in areas of deprivation for inactive adults with cardiovascular disease risk and/or mental health concerns? Study protocol for a pragmatic observational evaluation of the 'Active Herts' physical activity programme. BMJ Open. 2017;7:e017783.

    PubMed  PubMed Central  Google Scholar 

  77. 77.

    Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.

    Article  PubMed  PubMed Central  Google Scholar 

  78. 78.

    Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, Eccles MP, Cane J, Wood CE. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med. 2013;46:81–95.

    Article  Google Scholar 

  79. 79.

    Howlett N, Schulz J, Trivedi D, Troop N, Chater A. A prospective study exploring the construct and predictive validity of the COM-B model for physical activity. J Health Psychol. 2019;24(10):1378–91.

  80. 80.

    Howlett N, Trivedi D, Troop NA, Chater AM. Are physical activity interventions for healthy inactive adults effective in promoting behavior change and maintenance, and which behavior change techniques are effective? A systematic review and meta-analysis. Transl Behav Med. 2018;9:147–57.

    Article  PubMed  PubMed Central  Google Scholar 

  81. 81.

    NICE: Core components of a lifestyle weight management programme for overweight or obese adults. Weight management: lifestyle services for overweight or obese adults [https://pathways.nice.org.uk/pathways/lifestyle-weight-management-services-for-overweight-or-obese-adults#path=view%3A/pathways/lifestyle-weight-management-services-for-overweight-or-obese-adults/core-components-of-a-lifestyle-weight-management-programme-for-overweight-or-obese-adults.xml&content=view-node%3Anodes-weight-loss], accessed: [April 11, 2019].

  82. 82.

    Chater A. Motivational interviewing, health coaching and behaviour change. Enhancing communication skills for effective consultations. Training manual. Bedfordshire: SEPIA Health; 2015.

    Google Scholar 

  83. 83.

    McNeill A, Brose LS, Calder R, Bauld L, Robson D. E-cigarettes and heated tobacco products: evidence review. London: Public Health England; 2018.

    Google Scholar 

  84. 84.

    Walker N, Howe C, Glover M, McRobbie H, Barnes J, Nosa V, Parag V, Bassett B, Bullen C. Cytisine versus nicotine for smoking cessation. N Engl J Med. 2014;371:2353–62.

    Article  CAS  Google Scholar 

  85. 85.

    WHO. WHO Report on the Global Tobacco Epidemic, 2019. Geneva: Offer help to quit tobacco use; 2019.

    Google Scholar 

  86. 86.

    McNeill A, Brose LS, Calder R, Bauld L, Robson DJ. ArcbPHELPHE: Evidence review of e-cigarettes and heated tobacco products 2018; 2018. p. 6.

    Google Scholar 

  87. 87.

    National Academies of Sciences, Engineering, and Medicine. Public health consequences of e-cigarettes. Washington: National Academies Press; 2018.

  88. 88.

    Lancaster T, Stead LF. Self-help interventions for smoking cessation. Cochrane Database Syst Rev. 2005;3:CD001118.

  89. 89.

    Brown J, Michie S, Geraghty AW, Yardley L, Gardner B, Shahab L, Stapleton JA, West R. Internet-based intervention for smoking cessation (StopAdvisor) in people with low and high socioeconomic status: a randomised controlled trial. Lancet Respir Med. 2014;2:997–1006.

    Article  Google Scholar 

  90. 90.

    Ubhi HK, Michie S, Kotz D, Wong WC, West R. A mobile app to aid smoking cessation: preliminary evaluation of SmokeFree28. J Med Internet Res. 2015;17:e17.

    Article  PubMed  PubMed Central  Google Scholar 

  91. 91.

    Kahlmeier S, Wijnhoven TM, Alpiger P, Schweizer C, Breda J, Martin BW. National physical activity recommendations: systematic overview and analysis of the situation in European countries. BMC Public Health. 2015;15:133.

    Article  PubMed  PubMed Central  Google Scholar 

  92. 92.

    Chater A. Behaviour change intervention design, delivery & evaluation: what you really need to know when developing services. Cranfield Local Health Authority, Bedfordshire 2016.

  93. 93.

    Chater A. From design to evaluation… building an effective behaviour change intervention within public health: the ‘active Herts’ programme. Chisinau: Conference National Day of Health Promotion Specialist; 2018.

  94. 94.

    Curtis K, Fulton E, K B. Factors influencing application of behavioural science evidence by public health decision-makers and practitioners, and implications for practice. Prev Med Rep. 2018;12:106–15.

    Article  PubMed  PubMed Central  Google Scholar 

  95. 95.

    Vega J. Universal health coverage: the post-2015 development agenda. Lancet. 2013;381:179–80.

    Article  Google Scholar 

  96. 96.

    WHO. The world health report 2013: research for universal health coverage. Geneva: World Health Organization; 2013.

    Google Scholar 

Download references

Acknowledgments

The authors would like to acknowledge the contribution of Neil Howlett, Dashka Trivedi and Nicholas Troop from the University of Hertfordshire; and Andy Jones from the University of East Anglia, for their input into the Active Herts research and programme.

Funding

The conference on the Moldovan National Day of Health Promotion was funded by the Swiss Agency for Development and Cooperation (SDC) in the frame of the Healthy Life Project to reduce the burden of Non-Communicable Diseases in the Republic of Moldova. The Healthy Life Project is implemented by the Swiss Tropical and Public Health Institute, which funded the costs of publishing this proceedings paper.

Author information

Affiliations

Authors

Contributions

This manuscript included writing contributions by all of the authors. NS, DD, FG, LS, and AC were speakers at the conference and presented their different inputs during the two-day event. Each one of them contributed with writing up their presentation and with the discussion and recommendations. FS and SE provided extensive work in writing different sections of the manuscript while providing final edits to harmonise all sections with the journal guidelines. All authors read and approved this version of the manuscript.

Corresponding author

Correspondence to Helen Prytherch.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Sécula, F., Erismann, S., Cerniciuc, C. et al. Evidence-based policy making for health promotion to reduce the burden of non-communicable diseases in Moldova. BMC Proc 14, 1 (2020). https://doi.org/10.1186/s12919-020-0183-8

Download citation