Unhealthy eating is a societal challenge around the world provoking diseases such as obesity,
heart diseases, and some cancers, which are among the biggest cause of death (Ritchie & Roser,
2018). With mitigation and behavior change as a goal, risk communication has been pointed
out as a tool to transfer knowledge about Public Health decisions between different
stakeholders (Adekola et al., 2019; Zhang et al., 2020). While communication has been
proposed early on as a strategy to address public health topics (Hallahan et al., 2007; Werder,
2015; Zerfass et al., 2018), it has been suggested the desired level of knowledge is to be
achieved, both in society and in the academy (Bernadas, 2021; Diepeveen et al., 2013; Wise,
Risk perception does not impact only the general public, but all stakeholders involved in the
process, such as Experts and Govern (Adekola et al., 2019; Funk et al., 2022; Zhang et al.,
2020). The Health Belief Model (Rosenstock, 1974; Rosenstock et al., 1988) suggests that a
number of variables influence the likelihood of engaging in a different behavior, but how risk
communication can influence said variables are not yet fully understood. This is of high
importance, as policymakers' perception of risk and decisions influence the population as a
Our study aims to identify variables policymakers consider when evaluating the perceived
benefits, efficacy, and threats, before acting on a topic. We also intended to identify strategies
that have previously been used.
To go in deep into the topic, we’ve conducted a case study exploratory analysis, as it is the
preferred methodology to explore a contemporary event (Yin, 2009). Portugal was chosen as
the object of analysis as the country has a very specific context regarding public policies to
address healthy eating (Graça et al., 2018). Portugal’s first approach to the topic was in the ’70s
and formally creating a sectoral strategy and a decision entity in 2012 the National Program of
Healthy Eating (NPHE) (Graça, & Gregório, 2012). The strategy implemented was able to
intervene successfully in reducing sugar intake (Goiana-da-Silva et al., 2018), and still achieve
positive feedback from the public, even regarding taxes increment (Prada et al., 2020). The
same result could not be replicated regarding policies to reduce salt intake. Hence, we’ve
chosen to interview the current and the former first leaders of the NPHE, as they conducted the
intervention strategy development of both cases. Their point of view on the chain of events is
considered to be valuable, as they fall in the category of privileged witnesses who occupy a
position with acting power and responsibilities (Quivy & Campenhoudt, 1995).To collect data,
we’ve proceeded with exploratory interviews, as these help the researcher probe topics and
points of view not thought by himself (Quivy & Campenhoudt, 1995). Topics such as how
policymakers gather information for a decision process (Funk et al., 2022), the use of strategic
communication as a tool to promote health knowledge (Adekola et al., 2019; Ihlen, 2020;
Schiavo, 2013) and risk communications (Fischbacher;-Smith, 2012; Irwin, 2014) were the
main topics explored.
When implementing both strategies, the NPHE focused on five pilar topics: (1) Making clear
reference regarding where the money collected with special taxes would be used – the National
Healthcare System; (2) Stating that it was a policy developed to address a Public Health issue
and not as a strategy to raise the state’s revenue; (3) When referring to the reason why this was
needed, it would be addressed that the main goal was to protect children, as obesity levels
within that specific population had been increasing drastically; (4) Stating that all these efforts
were aligned with the World Health Organization strategy and insights; (5) Clearly stating that
only non-essential products would be affected by this and that it would not affect small and
medium national companies – being clear that it was aimed to affect big corporations. The
same strategy and methods did not work when they intended to address the salt intake topic.
The Portuguese Parliament rejected the intervention, not making it to the policy development
and implementation stage. Regarding this topic, the interviewed explained that two of the
political parties with parliamentary seats at the time evoked (1) that taxation on salt products
would impact the national industry and this would reflect on the job positions, causing
unemployment; The cultural values, habits, and traditions were also referred to (2) as a reason
not to intervene. Regarding this topic, it's been addressed that, overall, the idea that sugar is
bad for you is well received, but salt is often identified as an essential ingredient.
Regarding the reasons for not approving the interventions to address salt intake, it’s important
to highlight that political parties evoke cultural values and traditions, aligned with what has
been proposed regarding the impact of social norms and our decision process (Bicchieri, 2010;
Cialdini, 2007; Fekadu & Kraft, 2002; Perkins & Berkowitz, 1986). While further research is
needed to validate the topic, it seems imperative to analyze the trade-off between social norms,
tradition, and culture in despite of public health risk, much like has been proposed in the Health
Belief Model (Rosenstock, 1974; Rosenstock et al., 1988). When divided between public health
and tradition, a trade-off takes place. Risk communication might lead to the needed risk
perception. Social norms and the impact of interventions on the workforce seem to be topics
that concern those with executive power.
While it might have not been fully intentional, as the strategic program does not have a
communication advisor, the strategy seems to be aligned with the Seven Models of Framing
proposed by Hallahan (1999), to establish a common perspective on a topic. This exploratory
study allowed us to identify variables that influence a policy intervention. These should be
considered when planning a risk communication strategy to achieve the desired result – an
accurate transfer of knowledge and impact. Further research is needed to understand if risk
perception can influence the decision process, overruling the previously mentioned constructs
– if needed.
Adekola, J., Fischbacher-Smith, D., & Fischbacher-Smith, M. (2019). Light me up: Power and
expertise in risk communication and policy-making in the e-cigarette health debates. Journal
of Risk Research, 22(10), 1294–1308. Scopus.
Bernadas, J. M. A. C. (2021). Reimagining the “public” in public health: Exploring the
challenges of and opportunities for public relations research in public health in the Philippines.
Public Relations Review, 47(3), 102043. https://doi.org/10.1016/j.pubrev.2021.102043
Bicchieri, C. (2010). Norms, preferences, and conditional behavior. Politics, Philosophy &
Economics, 9(3), 297–313. https://doi.org/10.1177/1470594X10369276
Cialdini, R. B. (2007). Descriptive Social Norms as Underappreciated Sources of Social
Control. Psychometrika, 72(2), 263–268. https://doi.org/10.1007/s11336-006-1560-6
Diepeveen, S., Ling, T., Suhrcke, M., Roland, M., & Marteau, T. M. (2013). Public
acceptability of government intervention to change health-related behaviours: A systematic
review and narrative synthesis. BMC Public Health, 13(1), 756. https://doi.org/10.1186/1471-
Fekadu, Z., & Kraft, P. (2002). Expanding the Theory of Planned Behaviour: The Role of
Social Norms and Group Identification. Journal of Health Psychology, 7(1), 33–43.
Funk, T., Sharma, T., Chapman, E., & Kuchenmüller, T. (2022). Translating health information
into policy-making: A pragmatic framework. Health Policy, 126(1), 16–23.
Goiana-da-Silva, F., Nunes, A. M., Miraldo, M., Bento, A., Breda, J., & Araújo, F. F. (2018).
Fiscalidade ao Serviço da Saúde Pública: A Experiência na Tributação das Bebidas Açucaradas
em Portugal. Acta Médica Portuguesa, 31(4), 191. https://doi.org/10.20344/amp.10222
Graça, P., & Gregório, M. J. (2012). EVOLUÇÃO DA POLÍTICA ALIMENTAR E DE
NUTRIÇÃO EM PORTUGAL E SUAS RELAÇÕES COM O CONTEXTO
INTERNACIONAL. Alimentação Humana, 18(3), 79–96.
Graça, P., Gregório, M. J., de Sousa, S. M., Brás, S., Penedo, T., Carvalho, T., Bandarra, N.
M., Lima, R. M., Simão, A. P., Goiana-da-Silva, F., Freitas, M. G., & Araújo, F. F. (2018). A
new interministerial strategy for the promotion of healthy eating in Portugal: Implementation
and initial results. Health Research Policy and Systems, 16(1), 102.
Hallahan, K. (1999). Seven Models of Framing: Implications for Public Relations. Journal of
Public Relations Research, 11(3), 205–242. https://doi.org/10.1207/s1532754xjprr1103_02
Hallahan, K., Holtzhausen, D., van Ruler, B., Verčič, D., & Sriramesh, K. (2007). Defining
Strategic Communication. International Journal of Strategic Communication, 1(1), 3–35.
Ihlen, Ø. (2020). Science communication, strategic communication and rhetoric: The case of
health authorities, vaccine hesitancy, trust and credibility. Journal of Communication
Management, 24(3), 163–167. https://doi.org/10.1108/JCOM-03-2020-0017
Perkins, H. W., & Berkowitz, A. D. (1986). Perceiving the Community Norms of Alcohol Use
among Students: Some Research Implications for Campus Alcohol Education Programming *.
International Journal of the Addictions, 21(9–10), 961–976.
Prada, M., Rodrigues, D. L., Godinho, C. A., Lopes, D., & Garrido, M. V. (2020). Knowledge
and acceptance of interventions aimed at reducing sugar intake in Portugal. Public Health
Nutrition, 23(18), 3423–3434. https://doi.org/10.1017/S1368980020002165
Quivy, R., & Campenhoudt, L. V. (1995). Manual de Investigação em Ciências Sociais.
Ritchie, H., & Roser, M. (2018). Causes of death. https://ourworldindata.org/causes-of-death
Rosenstock, I. M. (1974). The Health Belief Model and Preventive Health Behavior. Health
Education Monographs, 2(4), 354–386. https://doi.org/10.1177/109019817400200405
Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social Learning Theory and the
Health Belief Model. Health Education Quarterly, 15(2), 175–183.
Schiavo, R. (2013). Health Communication: From Theory to Practice. John Wiley & Sons.
Werder, K. P. (2015). The Integration of Domains: Multidisciplinary Approaches to Strategic
Communication Campaigns. International Journal of Strategic Communication, 9(2), 79–86.
Wise, K. (2001). Opportunities for public relations research in public health. Public Relations
Review, 27(4), 475–487. https://doi.org/10.1016/S0363-8111(01)00102-3
Yin, R. K. (2009). Case Study Research: Design and Methods. SAGE.
Zerfass, A., Verčič, D., Nothhaft, H., & Werder, K. P. (2018). Strategic Communication:
Defining the Field and its Contribution to Research and Practice. International Journal of
Strategic Communication, 12(4), 487–505. https://doi.org/10.1080/1553118X.2018.1493485
Zhang, L., Li, H., & Chen, K. (2020). Effective Risk Communication for Public Health
Emergency: Reflection on the COVID-19 (2019-nCoV) Outbreak in Wuhan, China.
Healthcare, 8(1), 64. https://doi.org/10.3390/healthcare8010064