Strengthening Cross-cultural Policy Transfer: The Case of
Health Promotion and Action against Tobacco
Investigator: Albena Kerekovska, Department of Social
Medicine, Varna Medical University
The work refers to the issue of cross-cultural transfer of globally initiated health
promotion and tobacco control policies.
Rationale
At the dawn of the 21st century, globalisation is a word that has become a part of
everyday communication in all corners of the world. With the increasing
interdependence of countries, the emergence of transnational issues, and the growth of
international organizations - comparing and sharing policy experience to resolve
global problems becomes a necessary and an inevitable process. With the overall
tendency towards globalization, alongside the ongoing processes of European
integration, there is a major potential for global policies development and
implementation to distinctive localities. Therefore, a need to understand and enhance
the processes associated with global policy cross-cultural transfer is highly
acknowledged.
The European Region has changed dramatically for the last decade – geo-politically,
economically, and in terms of social development – with new challenges emerging all
the time. Alongside these changes has come the reality that health is not an issue that
can be discussed only in national terms. A new discussion has emerged which focuses
on public health at a global level . The widening international perspective on health
has moved up the global political agenda. Opportunities have been created to look for
strategies to assist health policy makers plan effectively in the new global
environment and implement global policies to diverse localities.
The focus on health promotion and tobacco control in this cross-cultural policy
research has been inspired by the processes of overall globalization and the widening
international perspective on health that have moved health policy and health
promotion up on the global political agenda. The globalization of tobacco marketing,
trade, research and industry influence represents a major threat to public health
worldwide. Tobacco use has been recognized as one of the greatest public health
challenges facing the world. Tobacco control has become an important item on the
policy agenda both – on a national and international level.
Within the new global realities and emerging transnational issues – the need has been
recognized to respond to global transition and focus resources on the development of
global health promotion policy that recognizes the intersectoral nature of health and
its determinants . Health promotion has become an important issue and a main feature
of modern health policies. Since the Ottawa Charter, the practice of health promotion
has developed considerably. The implementation of a wide range of health promotion
initiatives has generated much collective experience within Europe and added
considerably to both knowledge and progressive change.
Countries in Europe have taken health promotion initiatives to different stages of
development. While this has been more rapid and visible in the economically
developed countries, progress in the less developed countries has been slow. In
Eastern Europe, the promotion of health has been often hampered by social and
political difficulties. In many instances, economic and political priorities have been
inconsistent with the achievement of healthy public policy. However, the recent major
political and social changes in Eastern European countries – including Bulgaria - offer
new opportunities and open new perspectives for a wide range of policy areas,
including those of health and health promotion. The changed context of free-market
economy, democracy and decentralization has improved the prospects of policy
development for health. Health promotion has become a widely used notion there and
is gaining momentum. These countries have stated commitment and are struggling
their way towards European integration. There are better prospects now for Eastern
Europe to formulate and implement health promotion strategies that could meet the
new health challenges.
It has been acknowledged that “health promotion can only make sense as a ‘global’
phenomenon – its full value, impact and use cannot be appreciated by applying it
within one country or society” . Its imperative is a global application. But health
promotion, as it has developed in the industrialized west, is a product of Western
European psychological values and insights and thus cannot be regarded as neutral
product of scientific thought that can be applied readily to societies which do not
share the same values and have different cultural patterns.
Indeed, global health promotion policies and common approaches have been
developed, which are constructed exclusively for the cultural specifications and
societal levels of development of countries orientated towards the traditions of
Western Europe, Northern America and Australia. There has been a tendency to
assume that direct transfer is possible of these global policy documents to widely
differing environments without considering their socio-cultural specification and
language compatibility. This might lead to major difficulties for some nonwesternised countries in understanding some of the fundamental concepts developed
under global arrangements. Their language might not be immediately and easily
transferable, for instance, to Eastern European countries where connotations may be
politically sensitive or not culturally and socially aligned. The socio-cultural
differences that exist between the Eastern and Western parts of the European Region
might determine, in this particular case, difficulties associated with West–East policy
transfer. This raises some questions associated with global policies' language
compatibility and adaptation to become applicable and have a better fit for the
purpose of policy implementation in individual, unique socio-cultural settings.
The applicability of global health promotion policies to distinctive culturally specific
contexts becomes an important issue to be explored. A relevant question to be raised
is: Can we transfer global health promotion policy ideas cross-cultures with the
expectation they will universally work, or a translation of the global policy language
to the unique cultural setting and adaptation of the global policy concepts to the
distinctive context of policy implementation will be required?
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Purpose
The purpose of this work is to explore the process of cross-cultural transfer of health
promotion and tobacco control global policies, analyse the difficulties, propose
methods to overcome them, and test the approach in Bulgaria. The main hypothesis
tested throughout the overall study is that globally initiated health promotion policy
ideas can not be directly transferred cross cultures with the expectation they will
universally work. A specification of the global policy language will be required to the
unique cultural setting and adaptation of fundamental policy concepts to the specific
context of policy implementation.
The initial hypothesis is that globally produced (western-based) health promotion
policy will experience major difficulties of cross-cultural transfer, particularly as
related to Bulgaria. Proven, it logically calls for proposing methods that will help
overcome those difficulties and by which the language of internationally produced
health promotion global policies can be made locally applicable.
Outline Approach, Methods and Results
To meet the main purpose, the following logical sequence of stages is applied
throughout the thesis. It is started by setting the overall scene of the research, then the
main concepts and emerging issues are introduced. Next, a comparative study is
performed to explore the process of cross-cultural policy transfer and identify the
problems. An agenda is set for their resolution. Finally, an approach is developed and
tested for solving the problems and strengthening the process. On that basis,
conclusions are made, potential impacts are assessed, and prospects are opened for
future exploration. Each stage represents a separate part within the dissertation work.
Part I “Setting the Scene”– sets the overall scene of the research. Hereby, the
rationale, the research setting and the methods of study are introduced. It focuses on
the potentials and limits of cross-cultural approaches and comparative policy research
and explains the analytical framework that is chosen. Here, the theoretical aspects of
cross-cultural transfer are reviewed and the underlying transferability constraints are
explored. The notion of ‘cross-cultural policy transfer’ is also related to the emerging
issues of globalisation and European integration.
Part II “Policy Transfer of Health Promotion and Tobacco Control – Dimensions and
Developments” - provides clarification of the concepts and dimensions associated
with health promotion policy; and indicates how these concepts are to be used within
this particular work. It also concentrates on tobacco and tobacco control issues – the
world stage of development and conflict areas within policy formulation. In addition,
an overview of health promotion policy developments at the pan European level is
presented and some wider trends identified, which may have considerable relevance
as pre-accession and accession countries like Bulgaria consider health promotion
initiatives within the European context.
Part III “Transferring Health Policies Cross-culturally – Learning through Crossnational Case Analysis” - explores the process of cross-cultural policy transfer,
identifies the difficulties and constraints, and sets an agenda for their resolution. For
that purpose, a comparative cross-national case analysis is implied - based on two
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case studies (the UK and Bulgaria). The comparative cross-national research is used
here to gain insight in route of cross-cultural policy formulation and learn more about
the recipient of policy transfer (in this instance Bulgaria) by comparing it to a typical
Western sender of policy (the UK). This involves a study of health promotion and
tobacco control policies’ dynamics using a policy process oriented model of analysis.
The Walt Model of policy analysis takes account of the policy context and its
dynamics, the content of policy consideration, and the actors on the policy arena.
Identifying the main interests affected, the political, social and economic environment
and the various outcomes over time, this model seems particularly well suited for the
main purpose of the study.
Within this part of the work, the British experience of health promotion and tobacco
control policies within the European scene is reviewed and the realities of the
Bulgarian situation in respect to health promotion and tobacco control policy are also
analysed in order to set out the context of the recipient location of the cross-cultural
policy transfer exercise. Following this, possibilities are explored of how to transfer
the British experience into the Bulgarian context, and in the light of this to identify
difficulties as well as to propose ideas for better cross-cultural policy formulation.
Lessons arising from the experience in health promotion and tobacco control policy
development in the UK that might be of value to current developments and future
prospects in Bulgaria are also looked for.
The Hofstede’s four-dimensional model is applied as a major guiding tool to classify
the different national cultures of the two countries and to assess the constraints and
possibilities for cross-cultural policy transfer. It also serves as a foundation point for
bringing out the main hypothesis of the study.
Indeed, when dealing with the issue of cross-cultural policy transfer we are very much
involved in the matter of national cultural patterns and their impact on effective policy
transmission. The national cultural characteristics (as presented by Hofstede’s model)
prove to be specifically related to health promotion and thus influencing the
opportunities and constraints of cross-cultural policy transfer in this area.
The cross-cultural policy transfer exercise reveals major difficulties of global (western
produced) health promotion policy cross-cultural transfer to the Bulgarian realities.
Substantial difference is found in the national cultural characteristics of Bulgaria and
the UK, which reflects on the possibilities of cross-cultural policy transfer in health
promotion and tobacco control field. The language and understandings upon which
Western health promotion policies have been developed prove not to be congruent
with the analysis that is characterised by Hofstede’s cultural model as defined for
Bulgaria. The specific cultural model of Bulgaria does not seem to favour proper
understanding of health promotion policy language and provide a suitable context for
direct application of health promotion global concepts to the specific socio-cultural
realities of Bulgaria. In this sense, the way forward for health promotion policy
development in Bulgaria might bring to the necessity to look at the business of
adaptation of global policy items into a language that is culturally specific for the
country.
The specific case of transferring health promotion and tobacco control global policies
to the context of Bulgaria confirms the initial hypothesis of this work that policies
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designed within particular socio-cultural settings cannot be applied elsewhere
effectively or directly transferred to contexts that operate differently without
considering their socio-cultural specification and language compatibility. The direct
transfer of international health promotion policies into individual countries might be
culturally ineffective and contextually inapplicable. Therefore, a crucial pragmatic
task emerging from the cross-cultural transfer exercise is the development of an
approach, by which the language of health promotion global policies can be made
more applicable and have a better fit for the purpose of the country’s distinctive sociocultural setting.
The findings from the analysis based on the Hofstede’s model determine the need for
culturally specific language interpretation and adaptation of global policies to become
understandable and applicable to concrete distinctive contexts. Moreover, they help to
address the question of “How the main concepts and issues behind health promotion
- being designed under the western language paradigm - could be translated into the
language of countries having different cultural patterns?”
In the range of ideas advanced within the comparative cross-national research, a
major item identified is the one of ‘global policy language compatibility and
interpretation across cultures’, which might help overcome the difficulties involved
in cross-cultural policy transfer and strengthen that process. Assuming the necessity
for contextualization and adaptation of global health promotion policies to the context
of implementation the challenge is taken to look for an effective way of doing it. For
that purpose, the work continues with an empirical investigation that concentrates on
the pragmatic issues of how to modify the fundamental items under Health promotion
and Tobacco control and develop an interpretation that is in line with the cultural
specificities and realities of Bulgarian life.
Thus, the final part – Part IV “The Empirical Investigation” – develops and tests an
approach by which the language of internationally produced global policies can be
made locally applicable. The specific case of transferring international health
promotion policy messages to the Bulgarian context is used in this work to test that
approach. Its potential usability and implications to the process of accession to the EU
are also illustrated within this part.
For that purpose, the process of global policy transfer from the international to the
national level and further down - from the national to the sub-national level is
explored using the case of Bulgaria and addressing the issue of ‘cultural specificity’.
The transmission of international health promotion policy messages is considered here
within a process of communication and the Model of Communication Effectiveness is
used as a conceptual framework and an operational model of the empirical research.
It is suggested that the acceptability of International (western based) health promotion
policies by non-western national localities, in this case Bulgaria, can be enhanced by
cultural specification of the global policy language. The results achieved support the
idea that by contextual interpretation of health promotion international policy
language and its specification to the cultural pattern of Bulgaria we can increase the
acceptability and assure greater effectiveness in communicating global health
promotion policy messages on a national level.
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As cultural diversity also embraces all local and sub-state manifestations, we go
further down the vertical route of global policies transfer - from the national to the
sub-national level. The findings suggest also quite strongly that there is a cultural
specificity on a sub-national level that has affected the local receptivity to
international policy language. Thus, when transferring international policy ideas, apart
from the desensitisation and cultural specification of the global policy language to the
individual country, a further specification and a contextual adaptation will be also
required to the context of any particular locality of implementation within the country
in order to improve the transfer of those international ideas from the national to the
sub-national level.
Implications
The findings of this work could assist the process of better cross-cultural policy
formulation by overcoming the difficulties in cross-cultural policy transfer and
strengthening that process. The study objectives take into account the dynamic
developments of Bulgaria towards European integration as a pre-Accession country
and could assist proper understanding of negotiations within health areas and its
public health policy development. The main theme of this research has not been
explored so far in Bulgaria and it is also a rather new topic of study on the scene of
global policy research. The work could also have some major applications on a wider
basis. It might be of particular importance also for countries that are not in the western
group within Europe and have similar socio-cultural peculiarities.
Some potential impacts could also be considered for the process of accession to the
European Union. The Union is now expanding while experiencing great cultural
diversity, both – across Europe and within the individual states. Accession countries
like Bulgaria, for example, have to adapt now to global European policies and
principles which cannot be directly translated in the language of the domestic cultural
pattern. By overcoming the difficulties in cross-cultural policy transfer and
strengthening that process, the findings of this work could assist the adaptation of
global policy items into a language that is culturally specific for the country and the
sub-national levels; and thus – improve the implementation of global European
policies into distinctive localities.
We are witnessing now the ongoing processes of European integration. The existing
membership of the EU is diverse in its political origins, levels of development and
cultural perspectives. There are also distinctions and substantial cultural specificity on
the sub-national level. And the EU will experience even greater cultural diversity as it
is expanding. Whilst trying to create harmonisation and coherence it has a great
problem to cope with – to enhance the implementation of its global policies through
an adequate process of cross-cultural transfer - both across Europe and within
individual states.
The findings of this research could be of relevance to Global Public Policies
implementation in the big world of globalisation, harmonisation and European
integration. They suggest how to move ahead, particularly in a Union that is
expanding and which will experience even greater cultural diversity. Therefore, there
will be a utility to take the approach out from the specific context it was used and to
apply it in the broader context of accession to the EU.
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The time for seeking adequate solutions to global policies’ transfer, when considering
the unique context and its cultural constraints, could not be more opportune.
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