Publications by authors named "Peter Gelius"

36 Publications

Physical Activity as a Human Right?

Health Hum Rights 2021 Dec;23(2):201-211

Research associate at the Department of Sport Science and Sport at Friedrich-Alexander University Erlangen-Nuremberg and co-director of the WHO Collaborating Centre for Physical Activity and Public Health, Erlangen, Germany.

Public awareness of the importance of physical activity has increased due to the many lockdowns imposed during the COVID-19 pandemic. This has brought more widespread attention to a question previously confined primarily to parts of the physical activity promotion community: Do humans have a right to be active? While the public health benefits of physical activity are undisputed, up to now no clear understanding has emerged as to whether physical activity represents a human right. Even though the right to physical activity is not explicitly recognized in international human rights treaties, it seems possible to derive it from well-established human rights such as the right to health, the right to rest and leisure, the right to education, and the principle of nondiscrimination. This paper shows how a right to physical activity could be derived from international human rights treaties, how the attributes of such a right could be defined, and which state obligations would be associated with it. Given that the current human rights discourse in this field focuses mainly on the interconnections between sport and human rights, we would like to argue that there is added value in a debate about physical activity as a human right.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8694291PMC
December 2021

Toward the economic evaluation of participatory approaches in health promotion: lessons from four German physical activity promotion projects.

Health Promot Int 2021 Dec;36(Supplement_2):ii79-ii92

Centre for Health Economics (CHE), University of York, Heslington, York, YO10 5DD, UK.

Health promotion increasingly employs participatory approaches, but the question arises whether the likely higher costs of participation also translate into greater benefits. This article takes a first step toward a full health economic evaluation by comprehensively reporting the costs of a specific participatory approach, Cooperative Planning, in a German research consortium to promote physical activity. We conducted a costing analysis of Cooperative Planning at 22 sites across six settings. Project teams used a custom template to record resource use. We calculated average costs per meeting, site and setting using the opportunity costs approach, and obtained feedback from participating researchers. A total of 144 planning meetings with an average of nine participants were conducted. Costs per meeting varied significantly across settings. Differences were mostly attributable to varying meeting duration, preparation time and numbers of participants. Across settings, human resources accounted for roughly 95% of the costs. Implementing researchers reported challenges regarding the logic and methods of the health economic analysis. A participatory approach to physical activity promotion may cause substantially varying costs in different settings despite similar cost structures. However, their value for money could turn out comparably favorable if (and only if) the expected benefits is indeed forthcoming. Despite some challenges implementing the costing exercise into the logistics of ongoing participatory projects, this analysis may pave the way toward a full health economic evaluation, and the template may be useful to future participatory health promotion projects.
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http://dx.doi.org/10.1093/heapro/daab158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8670626PMC
December 2021

Cooperative planning and its utilization in German physical activity promotion: a brief introduction.

Health Promot Int 2021 Dec;36(Supplement_2):ii1-ii7

Department of Medicine, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA.

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http://dx.doi.org/10.1093/heapro/daab170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8670624PMC
December 2021

Policy Evaluation Network (PEN): Protocol for systematic literature reviews examining the evidence for impact of policies on physical activity across seven different policy domains.

HRB Open Res 2020 29;3:62. Epub 2021 Mar 29.

Physical Activity for Health, Health Research Institute, Department of Physical Education and Sport Sciences, University of Limerick, Limerick, Ireland.

Over 40 million deaths annually are due to noncommunicable diseases, 15 million of these are premature deaths and physical inactivity contributes an estimated 9% to this figure. Global responses have included the Sustainable Development Goals (SDGs) and the Global Action Plan on Physical Activity (GAPPA). Both point to policy action on physical activity (PA) to address change, yet the impact of policy on PA outcomes is unknown.  The protocol described outlines the methodology for systematic literature reviews that will be undertaken by the Policy Evaluation Network (PEN) to address this knowledge gap. The seven best investments for promotion of population PA identified in the Toronto Charter highlighted seven policy domains (schools, transport, urban design, primary health care systems, public education, community-wide programmes and sport) which will form the basis of these PEN reviews. Seven individual scientific literature searches across six electronic databases will be conducted. Each will use the key concepts of policy, PA, evaluation and a distinct concept for each of the seven policy domains. This will be supplemented with a search of the reference list of included articles. Methodological quality will be assessed and overall effectiveness for each included study will be described according to pre-determined criteria. Each review will provide policy makers with a list of policy statements and corresponding actions which the evidence has determined impact on PA directly or indirectly. By collating the evidence, and demonstrating the depth of the science base which informs these policy recommendations, each review will provide guidance to policymakers to use evidence-based or evidence-informed policies to achieve the 15% relative reduction in physical inactivity as defined by GAPPA.  PROSPERO CRD42020156630 (10/07/2020).
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http://dx.doi.org/10.12688/hrbopenres.13089.3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8567685.3PMC
March 2021

Monitoring of physical activity promotion in children and adolescents in the EU: current status and future perspectives.

Eur J Public Health 2021 Nov 17. Epub 2021 Nov 17.

European Office for the Prevention and Control of Noncommunicable Diseases, Regional Office for Europe, World Health Organization, Moscow, Russian Federation.

Background: Policy action is required to address physical inactivity in boys and girls. This action can be supported by international data collection, comparisons and sharing of good practices. Thus, this study aims to present and discuss the ongoing monitoring of physical activity (PA) indicators in children and adolescents in the 28 EU Member States.

Methods: Data on PA recommendations, PA prevalence, physical education (PE) and PA promotion programs for children and adolescents were provided by governments in a joint EU/WHO survey on the implementation status of the EU Council Recommendation on Health-Enhancing Physical Activity (HEPA) across Sectors.

Results: In 23 countries, national recommendations on PA are available. Detailed PA prevalence data among children and adolescents was available in 27 countries, in most cases separately for sex/gender and age groups. The total amount of PE lessons in schools differed greatly between countries and lessons were predominantly mandatory. After-school HEPA promotion programs were mostly implemented in EU Member States (78.6%), followed by active school breaks (57.1%), active travel to school (57.1%) and active breaks during school lessons (53.6%).

Conclusions: This study summarizes the monitoring of PA indicators among children and adolescents in all EU Member States by providing a comprehensive overview of the status of PA promotion and monitoring across the region. Based on our findings, it could be concluded that the current EU monitoring system on PA promotion should be adapted to provide evidence that can inform future policy development.
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http://dx.doi.org/10.1093/eurpub/ckab193DOI Listing
November 2021

Barriers and Facilitators of Physical Activity Participation in Adolescent Girls: A Systematic Review of Systematic Reviews.

Front Public Health 2021 15;9:743935. Epub 2021 Oct 15.

World Health Organization, Regional Office for Europe, Copenhagen, Denmark.

Persistent low physical activity (PA) levels among adolescent girls constitute a public health concern that calls for immediate and evidence-based policy action. This systematic review (SR) aimed to summarize evidence from SRs examining the barriers and facilitators of PA participation in adolescent girls. The objectives were to provide a synthesis of the available evidence and identify key areas for fostering gender-responsive action and policy implications. A comprehensive search of relevant SR and meta-analyses were performed in PubMed and Cochrane Library, until February 2021. Studies were included if they were SRs or meta-analyses, included adolescent girls aged between 10 and 19 years, and described barriers or facilitators of PA. Two independent authors performed the screening of potentially eligible studies and both assessed the methodological quality of included studies using the AMSTAR 2 tool. The barriers and facilitators were synthesized at environmental, interpersonal, and individual levels. A total of eight SRs were included in the qualitative synthesis. The most frequent barriers identified were the lack of support from peers, family, and teachers, and the lack of time. The most reported facilitators were weight loss, and support from peers, family, and teachers. Key areas for action and policy implementation include an inclusive approach to curriculum development to address gender norms; adequate training of professionals so they have a range of skills to ensure inclusion of adolescent girls; environmental changes in and out of schools to stimulate participation, to allow adolescent girls to be active in a safe and attractive environment; multistakeholder support at local, regional, and national level in incorporating a gender-responsive approach toward PA participation. The results highlight a variety of factors that influences the PA participation of adolescent girls. For the attainment of effective policies that increase PA levels in adolescent girls, it is essential to engage several stakeholders at different levels in incorporating a gender-responsive approach toward PA participation. PROSPERO, identifier: CRD42020204023.
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http://dx.doi.org/10.3389/fpubh.2021.743935DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8553996PMC
November 2021

Impact of the First Wave of COVID-19 on Physical Activity Promotion in the European Union: Results From a Policymaker Survey.

J Phys Act Health 2021 Oct 26:1-5. Epub 2021 Oct 26.

Background: The COVID-19 pandemic is a major challenge for societies and governments around the world that severely affects all aspects of health promotion. This study assesses the potential influence of the first wave of the pandemic on national physical activity promotion policy in the European Union (EU).

Methods: Data were collected using an online survey among members of the EU Physical Activity Focal Point Network, which consists of government officials from all EU member states.

Results: The COVID-19 pandemic has significantly affected physical activity promotion across the EU. In particular, experts indicated that it has negatively impacted opportunities for physical activity in their countries. There have, however, been positive effects of the crisis on public awareness of physical activity. While almost all countries were able to issue physical activity recommendations during quarantine, opinions varied regarding the overall impact of the pandemic on governmental capacities for physical activity promotion and policy.

Conclusions: This study shows that the COVID-19 crisis has had both negative and positive effects on physical activity promotion in the EU. The positive experiences reported by some members of the Focal Point Network may assist other countries in identifying potential policy windows and strategies for the ongoing pandemic.
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http://dx.doi.org/10.1123/jpah.2021-0083DOI Listing
October 2021

Policy Instruments for Health Promotion: A Comparison of WHO Policy Guidance for Tobacco, Alcohol, Nutrition and Physical Activity.

Int J Health Policy Manag 2021 Aug 25. Epub 2021 Aug 25.

Department of Sport Science and Sport, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.

Background: Policy is an important element of influencing individual health-related behaviours associated to major risk factors for non-communicable diseases (NCDs) such as smoking, alcohol consumption, unhealthy eating and physical inactivity. However, our understanding of the specific measures recommended in NCD prevention policy-making remains limited. This study analysed recent World Health Organization (WHO) documents to identify common policy instruments suggested for national NCD prevention policy and to assess similarities and differences between policies targeting different health-related behaviours.

Methods: Evert Vedung's typology of policy instruments, which differentiates between regulatory, economic/ fiscal and soft instruments, served as a basis for this analysis. A systematic search on WHO websites was conducted to identify documents relating to tobacco, alcohol, nutrition and physical activity. The staff of the respective units at the WHO Regional Office for Europe conducted an expert validation of these documents. The resulting documents were systematically searched for policy instruments. A word frequency analysis was conducted to estimate the use of individual instruments in the different policy fields, followed by an additional in-depth coding and content analysis by two independent reviewers.

Results: Across all health-related behaviours, the following policy instruments were suggested most frequently in WHO guidance documents: laws, regulations, standards, taxes, prices, campaigns, recommendations, partnerships and coordination. The analysis showed that regulatory and economic/fiscal policy instruments are mainly applied in tobacco and alcohol policy, while soft instruments dominate in the fields of nutrition and especially physical activity.

Conclusion: The study confirms perceived differences regarding recommended policy instruments in the different policy fields and supports arguments that "harder" instruments still appear to be underutilized in nutrition and physical activity. However, more comprehensive research is needed, especially with respect to actual instrument use and effectiveness in national-level NCD prevention policy.
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http://dx.doi.org/10.34172/ijhpm.2021.95DOI Listing
August 2021

[Policies to promote physical activity in Germany : An analysis based on a policy audit tool from the World Health Organization].

Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2022 Jan 27;65(1):107-115. Epub 2021 Aug 27.

Department für Sportwissenschaft und Sport, Friedrich-Alexander-Universität Erlangen-Nürnberg, Gebbertstraße 123 b, 91058, Erlangen, Deutschland.

Background: Physical inactivity is a key determinant of noncommunicable diseases. Therefore, the World Health Organization (WHO) as well as researchers worldwide have developed different tools to monitor and audit policies to promote physical activity. However, these tools have so far not been used to systematically collect and analyse data on physical activity promoting policies in Germany.

Aim: This study aims to provide a systematic overview of policies to promote physical activity in Germany.

Methods: The study was conducted as part of the Policy Evaluation Network ( www.jpi-pen.eu ). Data from the European Union Physical Activity Monitoring Framework, desk research, and an expert survey were utilised and collected with the WHO's health-enhancing physical activity (HEPA) policy audit tool (PAT).

Results: The results highlight the wide range of relevant stakeholders and provide an overview of current policies as well as surveillance, evaluation, and funding. Significant accomplishments and persistent challenges are identified.

Discussion: An international comparison shows that, in contrast to Germany, other countries have formulated measurable goals for physical activity promotion on a national level. However, Germany is among a minority of countries with specific physical activity recommendations for adults with noncommunicable diseases. Further structural development of physical activity promotion in Germany is necessary.
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http://dx.doi.org/10.1007/s00103-021-03403-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8732938PMC
January 2022

Physical inactivity in nine European and Central Asian countries: an analysis of national population-based survey results.

Eur J Public Health 2021 10;31(4):846-853

WHO European Office for the Prevention and Control of Noncommunicable Diseases, Moscow, Russian Federation.

Background: Physical inactivity is a major risk factor for non-communicable diseases. However, recent and systematically obtained national-level data to guide policy responses are often lacking, especially in countries in Eastern Europe and Central Asia. This article describes physical inactivity patterns among adults in Armenia, Azerbaijan, Belarus, Georgia, Kyrgyzstan, Republic of Moldova, Tajikistan, Turkey and Uzbekistan.

Methods: Data were collected using the Global Physical Activity Questionnaire drawing nationally representative samples of adults in each country. The national prevalence of physical inactivity was calculated as well as the proportional contribution to total physical activity (PA) during work, transport and leisure-time. An adjusted logistic regression model was applied to analyze the association of age, gender, education, household status and income with physical inactivity.

Results: National prevalence of physical inactivity ranged from 10.1% to 43.6%. The highest proportion of PA was registered during work or in the household in most countries, whereas the lowest was during leisure-time in all countries. Physical inactivity was more likely with older age in eight countries, with female gender in three countries, and with living alone in three countries. There was no clear pattern of association with education and income.

Conclusion: Prevalence of physical inactivity is heterogeneous across the region. PA during leisure-time contributes minimally to total PA in all countries. Policies and programs that increase opportunities for active travel and leisure-time PA, especially for older adults, women and people living alone will be an essential part of strategies to increase overall population PA.
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http://dx.doi.org/10.1093/eurpub/ckab028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8504998PMC
October 2021

Scientific Cooperation and the Co-production of Scientific Outcomes for Physical Activity Promotion: Results From a Transdisciplinary Research Consortium.

Front Public Health 2021 11;9:604855. Epub 2021 Jun 11.

Department of Sport Science and Sport, Friedrich-Alexander-University of Erlangen-Nuremberg, Erlangen, Germany.

To tackle complex societal challenges such as the high prevalence of physical inactivity, research funding is increasingly channeled toward cross-disciplinary research consortia. This study focused on exchange and cooperation (E&C) among the scientists of a 5-year transdisciplinary research initiative in Germany. Researchers' perceptions of E&C were combined with numbers of collaborative products during the project's life to make the developments of E&C and the quality of collaborative products visible. We applied a mixed-methods design including a qualitative content analysis of pre-interviews, focus-group interviews, and documents as well as a quantitative analysis of research (scientific publications, books, conference participations) and training outcomes (supervised bachelor's, master's, and Ph.D. theses). Inductive and deductive approaches were combined to analyze factors of collaborative readiness and to identify perceptions of E&C among project teams. Based on Hall et al.'s "Conceptual Model for Evaluation of Collaborative Initiatives," the project period was separated into phases of "collaborative readiness," "collaborative capacity," and "collaborative products." Our findings revealed a discrepancy between the objectively assessed concepts of collaborative readiness and researchers' reported perceptions of E&C during the early project stage. A set of E&C hindering factors identified during the initial project phase remained present until the final project stage. Further, E&C among scientists increased over time, as reflected by researchers' perceptions. Reports of scientists also showed that outcomes were co-produced at the final project stage for the first time, while knowledge integration had not yet been achieved. Generally, the number of collaborative products (particularly scientific publications) also substantially increased over time. E&C was supported and promoted by the efforts of the coordinating sub-project. Scientific E&C is a learning process and needs time to develop. A participatory research approach taking into account the perspectives on and requirements for E&C during the project's design might lay the ground for suitable, supportive, and transparent conditions for effective and successful E&C. Despite their time- and resource-consuming nature, cross-disciplinary research initiatives provide a fertile context in which to generate new solutions for pressing societal issues given that long-term funding and the establishment of an overarching coordination organ is assured.
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http://dx.doi.org/10.3389/fpubh.2021.604855DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8232050PMC
July 2021

Physical activity referral scheme components: a study protocol for systematic review and meta-regression.

BMJ Open 2021 06 18;11(6):e049549. Epub 2021 Jun 18.

Department of Sport Science and Sport, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Bayern, Germany.

Introduction: In its attempt to establish effective physical activity promotion methods, research on physical activity referral schemes (PARS) is attracting significant attention. Sometimes known as physical activity on prescription schemes, PARS involve a well-defined procedure whereby a primary healthcare professional introduces a participant to the topic of physical activity and employs prescription or referral forms to connect the participant to physical activity opportunities, such as local fitness offers. The planned systematic review will focus on these referral routes and scheme components and how they are integrated into various PARS models worldwide. We seek to identify the evidence-based core components that play the most important roles in the effectiveness of PARS.

Methods And Analysis: The development and reporting of the protocol follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We plan to conduct a systematic main literature search on PubMed, Scopus, Web of Science, CINAHL, HTA, SpringerLink and other databases. We will include studies that report outcomes on physical activity, PARS uptake and adherence rates or descriptive information about PARS models. We intend for all review stages, citation screening, data extraction and risk of bias assessment to be conducted by at least two independent reviewers. As a broad spectrum of study designs, including randomised and non-randomised studies of interventions and mixed methods, will be eligible, we will use three separate tools to assess the risk of bias in individual studies. The data will be primarily synthesised narratively, following Intervention Component Analysis. If the data allow, we will perform a random-effects meta-analysis and meta-regression to investigate the impact of specific PARS components on effect sizes.

Ethics And Dissemination: This systematic review does not require formal ethics approval. The results will be submitted to a peer-reviewed journal and international conferences to reach the scientific community.

Prospero Registration Number: CRD42021233229.
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http://dx.doi.org/10.1136/bmjopen-2021-049549DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8215250PMC
June 2021

Promoting health-enhancing physical activity in Europe: Surveillance, policy development and implementation 2015-2018.

Health Policy 2021 08 25;125(8):1023-1030. Epub 2021 May 25.

World Health Organization Regional Office for Europe, Copenhagen, Denmark; European Office for the Prevention and Control of Noncommunicable Diseases, World Health Organization Regional Office for Europe, Moscow, Russian Federation.

In the European Union (EU), the low levels of health-enhancing physical activity (HEPA) and high levels of sedentary behaviour are a concerning public health issue common to all Member States. In 2013, the Council of the EU recognized the need for more data related to HEPA to support policymaking across the region and proposed a monitoring framework that included 23 indicators covering different themes relevant to HEPA promotion in the EU context. In 2014, the EU Physical Activity Focal Points Network was established to support the implementation of the monitoring framework and in 2015 and 2018 surveys were conducted to collect epidemiological and policy information related to HEPA for each Member State. This paper aims to provide an update on the status of HEPA policies and surveillance in the EU and describe the changes that have occurred since 2015. In 2018, all countries had implemented more than 10 indicators, 8/28 had implemented 20 or more indicators, and only one country had completed all 23 indicators. From 2015 to 2018, 19 indicators improved, one remained unchanged, and three regressed. From the country perspective, 17 improved the number of accomplished indicators, five maintained the indicators, and five worsened the number of indicators. Overall, there has been a clear increase in the number of countries implementing HEPA policies and strategies across the different sectors, although some heterogeneity between Members Sates was still observed. Implementation of regional physical activity strategies and the establishment of the EU-wide monitoring framework appears to have had an overall positive impact on HEPA policy development and implementation.
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http://dx.doi.org/10.1016/j.healthpol.2021.05.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8450183PMC
August 2021

Development of national physical activity recommendations in 18 EU member states: a comparison of methodologies and the use of evidence.

BMJ Open 2021 04 15;11(4):e041710. Epub 2021 Apr 15.

European Office for the Prevention and Control of Noncommunicable Diseases, World Health Organization Regional Office for Europe, Moscow, Russian Federation.

Objectives: The aim of the study is to compare how member states of the European Union (EU) develop their national physical activity (PA) recommendations and to provide an overview of the methodologies they apply in doing so. Information was collected directly from the physical activity focal points of EU member states in 2018. Five countries were chosen for detailed case study analysis of development processes.

Design: Cross-sectional survey.

Participants: The representatives of the 28 EU member state governments to the EU physical activity Focal Point Network.

Outcome Measures: From national documents we extracted data on (1) the participants of the development process, (2) the different methods used during development, and (3) on which sources national PA recommendations were based. An additional survey for case study countries provided details on (1) anonymised information on the participants of development process, (2) methods employed and rationale for choosing them, (3) development process and timeline, and (4) main source documents used for recommendation development.

Results: Eighteen national documents on PA recommendations contained information about development process. The results showed that countries used different approaches to develop national recommendations. The main strategies were (1) adoption of WHO 2010 recommendations or (2) a combination of analysis and adoption of other national and international recommendations and literature review. All of the five case study countries relied on review processes rather than directly adopting WHO recommendations.

Conclusions: While there are arguments for the use of particular strategies for PA recommendation development, there is currently no evidence for the general superiority of a specific approach. Instead, our findings highlight the broad spectrum of potential development methods, resources utilisation and final recommendations design currently available to national governments. These results may be a source of inspiration for other countries currently planning the development or update of national PA recommendations.
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http://dx.doi.org/10.1136/bmjopen-2020-041710DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8054104PMC
April 2021

[Evidence-based primary prevention and health promotion: methods and procedures in 5 research consortia].

Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2021 May 9;64(5):581-589. Epub 2021 Apr 9.

Abteilung Prävention und Evaluation, Leibniz-Institut für Präventionsforschung und Epidemiologie - BIPS, Achterstr. 30, 28359, Bremen, Deutschland.

Between 2014 and 2022, the 5 German research networks AEQUIPA, CAPITAL4HEALTH, HLCA, PartKommPlus, and SMARTACT are investigating topics of primary prevention and health promotion with the aim of further deepening the evidence base in these areas. The work of the 5 research networks for primary prevention and health promotion is presented, analysed, and discussed from an internal perspective. A model of evidence-based public health serves as a structuring framework.The 5 research networks use a variety of access routes for the generation of evidence with regard to the participation of nonacademic, civil society actors and users. There is a wide range of study designs - from randomised controlled trials and systematic reviews to diverse qualitative designs. The use of models and theories supports the evidence base. Beyond evidence generation, all research networks focus on at least exemplary implementation of new evidence.Due to the diversity of methods, a diversified evidence-based approach can be realised, taking into account network-specific aspects. Structural circumstances limit the further systematic strengthening of the evidence base. In particular, the involvement of nonacademic, civil society actors for the work with hard-to-reach target groups often cannot be financed or is considered too time consuming under the given circumstances. The COVID-19 pandemic highlights the importance of a flexible spectrum of methods, employing both digital and analogue methods in a meaningful way.
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http://dx.doi.org/10.1007/s00103-021-03322-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8033542PMC
May 2021

Development, implementation, evaluation and scaling-up of physical activity referral schemes in Germany: protocol for a study using a co-production approach.

BMJ Open 2021 03 22;11(3):e045563. Epub 2021 Mar 22.

Department of Sport Science and Sport, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.

Introduction: Physical activity referral schemes (PARSs) are recommended to promote physical activity (PA) among adults at risk of developing or with established non-communicable diseases (NCDs). In Germany, this kind of referral schemes has not yet been implemented systematically and nationwide. In this study protocol, we present the methodological design of a co-production research study aimed at establishing a PARS for adults with NCDs in German primary healthcare.

Methods And Analysis: We will employ a co-production approach consistently throughout the four project phases: (1) development of the PARS; (2) preparation period; (3) implementation and evaluation; (4) development of a strategic plan for scaling up the PARS to the national level as part of standard care. The first phase will additionally include a status quo analysis of the existing physical activity pathways nationwide as well as an overview of international PARS models. A pragmatic trial design will be used for evaluating the developed PARS. The co-production approach will involve relevant actors in the German healthcare system, namely, healthcare service providers (eg, physicians, exercise professionals), health insurance providers, exercise providers, patients' representatives, experts in the development and implementation of educational concepts, and scientists from the fields of sports science and public health.

Ethics And Dissemination: The project has been reviewed and approved by the ethics committee of the Friedrich-Alexander-University Erlangen-Nürnberg (ethics approval number: 331_20 B). Through cooperation agreements, the stakeholders involved gave their consent to participate and were informed about the study in detail. The results of this study will be disseminated by international conference presentations and peer-reviewed publications, and if possible, a manual for the use of the PARS will be provided.
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http://dx.doi.org/10.1136/bmjopen-2020-045563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986939PMC
March 2021

Physical activity promotion in the age of climate change.

F1000Res 2020 11;9:349. Epub 2020 May 11.

Department for Sport Science and Sport, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, 91054, Germany.

The importance of the global climate crisis requires linking physical activity promotion and climate action. This article provides a first overview of interconnections between physical activity promotion and climate action, potential synergies and discrepancies, aiming to stimulate further discussion about this topic. The analysis is based on the World Health Organization's Global Action Plan on Physical Activity 2018-2030 (GAPPA). The GAPPA covers five perspectives that are of particular relevance with respect to potential links with climate policy: (1) Infrastructures supporting active transport, (2) green spaces and recreational/exercise facilities, (3) exercise programs, (4) mass communication campaigns and mass participation events and (5) training of professionals. Our analysis demonstrates a considerable alignment between strategies for physical activity promotion and efforts for the reduction of greenhouse gas emissions. However, in some of the areas, this alignment could still be improved. Additionally, more climate-conscious policies, research and surveillance need to be developed in the field of physical activity promotion.
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http://dx.doi.org/10.12688/f1000research.23764.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7883311PMC
March 2021

The added value of using the HEPA PAT for physical activity policy monitoring: a four-country comparison.

Health Res Policy Syst 2021 Feb 15;19(1):22. Epub 2021 Feb 15.

Physical Activity for Health Research Cluster, Health Research Institute, University of Limerick, Limerick, Ireland.

Background: Public policy is increasingly recognized as an important component of physical activity promotion. This paper reports on the current status of physical activity policy development and implementation in four European countries based on the Health-Enhancing Physical Activity Policy Audit Tool (HEPA PAT) developed by WHO. It compares the findings to previous studies and discusses the general utility of this tool and its unique features in relation to other instruments.

Methods: The study was conducted as part of the Policy Evaluation Network ( www.jpi-pen.eu ) in Germany, Ireland, the Netherlands and Poland. Data collection built upon information obtained via the EU Physical Activity Monitoring Framework survey, additional desk research and expert opinion. Data analysis employed Howlett's policy cycle framework to map and compare national physical activity policies in the four countries.

Results: In all countries under study, policy agenda-setting is influenced by prevalence data from national health monitoring systems, and the sport and/or health sector takes the lead in policy formulation. Key policy documents were located mainly in the health sector but also in sport, urban design and transport. Physical activity programmes implemented to meet policy objectives usually cover a broad range of target groups, but currently only a small selection of major policies are evaluated for effectiveness. National experts made several suggestions to other countries wishing to establish physical activity policies, e.g. regarding cross-sectoral support and coordination, comprehensive national action plans, and monitoring/surveillance.

Conclusions: This study provides a detailed overview of physical activity policies in the four countries. Results show that national governments are already very active in the field but that there is room for improvement in a number of areas, e.g. regarding the contribution of sectors beyond sport and health. Using the HEPA PAT simultaneously in four countries also showed that procedures and timelines have to be adapted to national contexts. Overall, the instrument can make an important contribution to understanding and informing physical activity policy, especially when used as an add-on to regular monitoring tools like the EU HEPA Monitoring Framework.
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http://dx.doi.org/10.1186/s12961-021-00681-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885477PMC
February 2021

Community-Based Approaches to Reducing Health Inequities and Fostering Environmental Justice through Global Youth-Engaged Citizen Science.

Int J Environ Res Public Health 2021 01 21;18(3). Epub 2021 Jan 21.

Faculty of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia.

Growing socioeconomic and structural disparities within and between nations have created unprecedented health inequities that have been felt most keenly among the world's youth. While policy approaches can help to mitigate such inequities, they are often challenging to enact in under-resourced and marginalized communities. Community-engaged participatory action research provides an alternative or complementary means for addressing the physical and social environmental contexts that can impact health inequities. The purpose of this article is to describe the application of a particular form of technology-enabled participatory action research, called the citizen science research model, with youth. An overview of 20 studies occurring across five continents indicates that youth and young adults from varied backgrounds and with interests in diverse issues affecting their communities can participate successfully in multiple contributory research processes, including those representing the full scientific endeavor. These activities can, in turn, lead to changes in physical and social environments of relevance to health, wellbeing, and, at times, climate stabilization. The article ends with future directions for the advancement of this type of community-engaged citizen science among young people across the socioeconomic spectrum.
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http://dx.doi.org/10.3390/ijerph18030892DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7908382PMC
January 2021

The evidence for the impact of policy on physical activity outcomes within the school setting: A systematic review.

J Sport Health Sci 2021 05 19;10(3):263-276. Epub 2021 Jan 19.

Department of Physical Education and Sport Sciences, Health Research Institute, University of Limerick, Limerick V94 T9PX, Ireland.

Background: Despite the well-established health benefits of physical activity (PA) for young people (aged 4-19 years), most do not meet PA guidelines. Policies that support PA in schools may be promising, but their impact on PA behavior is poorly understood. The aim of this systematic review was to ascertain the level and type of evidence reported in the international scientific literature for policies within the school setting that contribute directly or indirectly to increasing PA.

Methods: This systematic review is compliant with Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Six databases were searched using key concepts of policy, school, evaluation, and PA. Following title and abstract screening of 2323 studies, 25 progressed to data synthesis. Methodological quality was assessed using standardized tools, and the strength of the evidence of policy impact was described based on pre-determined codes: positive, negative, inconclusive, or untested statistically.

Results: Evidence emerged for 9 policy areas that had a direct or indirect effect on PA within the school setting. These were whole school PA policy, physical education, sport/extracurricular PA, classroom-based PA, active breaks/recess, physical environment, shared use agreements, active school transport, and surveillance. The bulk of the evidence was significantly positive (54%), 27% was inconclusive, 9% was significantly negative, and 11% was untested (due to rounding, some numbers add to 99% or 101%). Frequency of evidence was highest in the primary setting (41%), 34% in the secondary setting, and 24% in primary/secondary combined school settings. By policy area, frequency of evidence was highest for sport/extracurricular PA (35%), 17% for physical education, and 12% for whole school PA policy, with evidence for shared use agreements between schools and local communities rarely reported (2%). Comparing relative strength of evidence, the evidence for shared use agreements, though sparse, was 100% positive, while 60% of the evidence for whole school PA policy, 59% of the evidence for sport/extracurricular PA, 57% of the evidence for physical education, 50% of the evidence for PA in classroom, and 50% of the evidence for active breaks/recess were positive.

Conclusion: The current evidence base supports the effectiveness of PA policy actions within the school setting but cautions against a "one-size-fits-all" approach and emphasizes the need to examine policy implementation to maximize translation into practice. Greater clarity regarding terminology, measurement, and methods for evaluation of policy interventions is needed.
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http://dx.doi.org/10.1016/j.jshs.2021.01.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8167338PMC
May 2021

Physical Activity, Screen Time, and Sleep Duration of Children Aged 6-9 Years in 25 Countries: An Analysis within the WHO European Childhood Obesity Surveillance Initiative (COSI) 2015-2017.

Obes Facts 2021 22;14(1):32-44. Epub 2020 Dec 22.

National Institute of Health Dr Ricardo Jorge I.P., Lisbon, Portugal.

Background: Children are becoming less physically active as opportunities for safe active play, recreational activities, and active transport decrease. At the same time, sedentary screen-based activities both during school and leisure time are increasing.

Objectives: This study aimed to evaluate physical activity (PA), screen time, and sleep duration of girls and boys aged 6-9 years in Europe using data from the WHO European Childhood Obesity Surveillance Initiative (COSI).

Method: The fourth COSI data collection round was conducted in 2015-2017, using a standardized protocol that included a family form completed by parents with specific questions about their children's PA, screen time, and sleep duration.

Results: Nationally representative data from 25 countries was included and information on the PA behaviour, screen time, and sleep duration of 150,651 children was analysed. Pooled analysis showed that: 79.4% were actively playing for >1 h each day, 53.9% were not members of a sport or dancing club, 50.0% walked or cycled to school each day, 60.2% engaged in screen time for <2 h/day, and 84.9% slept for 9-11 h/night. Country-specific analyses of these behaviours showed pronounced differences, with national prevalences in the range of 61.7-98.3% actively playing for >1 h/day, 8.2-85.6% were not members of a sport or dancing club, 17.7-94.0% walked or cycled to school each day, 32.3-80.0% engaged in screen time for <2 h/day, and 50.0-95.8% slept for 9-11 h/night.

Conclusions: The prevalence of engagement in PA and the achievement of healthy screen time and sleep duration are heterogenous across the region. Policymakers and other stakeholders, including school administrators and parents, should increase opportunities for young people to participate in daily PA as well as explore solutions to address excessive screen time and short sleep duration to improve the overall physical and mental health and well-being of children.
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http://dx.doi.org/10.1159/000511263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7983588PMC
July 2021

[Cooperative planning of measures to promote physical activity : New paths for expanding capabilities-results from the Capital4Health research consortium].

Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2021 Feb 14;64(2):187-198. Epub 2020 Dec 14.

Department für Sportwissenschaft und Sport, Friedrich-Alexander-Universität Erlangen-Nürnberg, Gebbertstr. 123 b, 91058, Erlangen, Deutschland.

Background: Despite various national and international political initiatives for promoting physical activity at the population level, the development of effective interventions for physical activity promotion remains a challenge. In this context, there is a growing interest in participatory approaches that actively involve central setting actors in the development of specific measures.

Aim Of The Article: This article reports on the experience made by the Capital4Health research consortium while using a participatory approach called "cooperative planning" to increase capabilities for physical activity across different age groups.

Results: Capital4Health employed the cooperative planning approach in the childcare, school, vocational training (car mechatronics and nursing), and community setting (with a focus on men 50+). While the central elements of the approach were implemented in all settings, planning processes varied significantly with respect to the spectrum of involved actors, the number of participants and sessions, the specific measures developed, the evaluation methods, and the effects achieved at an individual and systems level.

Conclusion: From the perspective of the Capital4Health principal investigators, the preliminary empirical results from the different settings allow for the overall conclusion that the cooperative planning approach can work and generate health promotion impact in very different settings. However, it must (and can) be adapted to the respective setting, especially in relation to involving population groups. Actors' readiness for change is crucial, as physical activity does not always have top priority in settings. In this context, key individuals can make a decisive contribution to a project's success.
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http://dx.doi.org/10.1007/s00103-020-03263-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7843529PMC
February 2021

The capability approach as a bridging framework across health promotion settings: theoretical and empirical considerations.

Health Promot Int 2021 Apr;36(2):493-504

Department of Sport Science and Sport, Friedrich-Alexander University Erlangen-Nuremberg, Gebbertstraße 123b, 91058 Erlangen, Germany.

Health promotion research has increasingly called for transdisciplinary approaches. Such calls ask for bridging frameworks that define comprehensive sets of health determinants and appropriately conceptualize the roles of population groups as well as other relevant actor groups in the co-production of health. This article aims to present the seminal capability approach by Sen and Nussbaum as a potentially suitable framework for such bridging endeavors to guide health promotion research. It highlights domains of the capability approach that appear to be particularly relevant to bridging diverse disciplines and settings. Such domains particularly refer to the agency of decisive actor groups (population groups, professionals, policymakers and researchers) as well as to the differentiation of personal, social and environmental conversion factors that disciplines define within their specific epistemologies and ontologies. The article uses empirical examples from a German research consortium that aimed to promote physical activity in five different settings while fostering cooperation and conceptual alignment between several academic disciplines and sub-disciplines to highlight benefits and challenges of using the capability approach as a bridging framework for transdisciplinary health promotion. We conclude that the capability approach might serve as bridging framework to guide future transdisciplinary research if partners involved continuously exchange to develop a shared understanding of the issues to be researched.
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http://dx.doi.org/10.1093/heapro/daaa076DOI Listing
April 2021

What are effective policies for promoting physical activity? A systematic review of reviews.

Prev Med Rep 2020 Jun 8;18:101095. Epub 2020 Apr 8.

Friedrich-Alexander University Erlangen-Nuremberg, Gebbertstraße 123b, 91058 Erlangen, Germany.

The importance of policy for promoting physical activity (PA) is increasingly recognized by academics, and there is a push by national governments and international institutions for PA policy development and monitoring. However, our knowledge about which policies are actually effective to promote PA remains limited. This article summarizes the currently available evidence by reviewing existing reviews on the subject. Building on results from a previous scoping review on different types of PA-related evidence, we ran searches for combinations of the terms "physical activity", "evidence", "effect", "review", and "policy" in six different databases (PubMed, Scopus, SportDiscus, PsycInfo, ERIC, and IBSS). We used EPPI Reviewer 4 to further process the results and conduct an in-depth analysis. We identified 57 reviews providing evidence on 53 types of policies and seven broader groups of policies. Reviews fell into four main categories: 1) setting- and target group-specific; 2) urban design, environment and transport; 3) economic instruments; and 4) broad-range perspective. Results indicate that there is solid evidence for policy effectiveness in some areas (esp. school-based and infrastructural policies) but that the evidence in other areas is insufficient (esp. for economic policies). The available evidence provides some guidance for policy-makers regarding which policies can currently be recommended as effective. However, results also highlight some broader epistemological issues deriving from the current research. This includes the conflation of PA policies and PA interventions, the lack of appropriate tools for benchmarking individual policies, and the need to critically revisit research methodologies for collating evidence on policies.
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http://dx.doi.org/10.1016/j.pmedr.2020.101095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7182760PMC
June 2020

Physical activity promotion in German vocational education: does capacity building work?

Health Promot Int 2020 Dec;35(6):1577-1589

Department of Sport Science and Sport, Friedrich-Alexander University Erlangen-Nuremberg, Gebbertstraße 123b, 91058 Erlangen, Germany.

Apprentices in many sectors are exposed to increased health risks and show low levels of physical activity (PA). Environmental and policy approaches seem to be promising tools for PA promotion as they can positively influence the context in which PA occurs. This article reports results from a German research project (2015-2018) that developed and implemented measures for PA promotion in the field of vocational education (VE). A participatory approach-cooperative planning (COP)-involving researchers as well as stakeholders from policy and practice was used in two VE settings-nursing care and automotive mechatronics. We assessed the extent to which new capacities for PA promotion were created by conducting semi-structured interviews with stakeholders from both sectors (n = 12) and one group interview with nursing students (n = 4). Transcripts were analysed using qualitative content analysis. Findings show that new capacities were created mainly in the form of resources and opportunities and that several measures for PA promotion (e.g. a regular lesson on the issue of PA and health and a tutoring system) were successfully integrated into VE routines. However, establishing new organizational goals and obligations appeared to be challenging. Moreover, the article presents influencing factors, such as the participation of the main actors that strongly supported the process of capacity building within their organization. We conclude that COP seems promising in creating new capacities for PA promotion in the field of VE, and therefore has the potential to promote a physically active lifestyle among apprentices.
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http://dx.doi.org/10.1093/heapro/daaa014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7785309PMC
December 2020

Status and contents of physical activity recommendations in European Union countries: a systematic comparative analysis.

BMJ Open 2020 02 20;10(2):e034045. Epub 2020 Feb 20.

Division of Noncommunicable Diseases and Promoting Health through the Life-course, World Health Organization Regional Office for Europe, Copenhagen, Denmark.

Objectives: We analysed the information on current national physical activity recommendations in all EU Member States provided by governments in a joint EU/WHO survey on the implementation status of the EU Council Recommendation on Health-Enhancing Physical Activity across Sectors.

Design: Cross-sectional survey.

Participants: The representatives of the 28 EU Member State governments to the EU Physical Activity Focal Point Network.

Outcome Measures: National recommendations on: (A) minimum frequency, duration, intensity and lengths of bouts of physical activity, (B) preventing inactivity or sedentary behaviour and (C) further recommendations for additional health benefits, obesity prevention and specific types of activity.

Results: An official document could be located for 23 of the 28 EU Member States, while four are currently developing recommendations. For children and adolescents, most countries follow the 2010 WHO Global Recommendations for Physical Activity, but there are notable differences in the delimitation of age groups. 14 countries also followed WHO in their recommendations for adults, and 11 countries have additional advice on avoiding inactivity and sitting among adults. 18 Member States have recommendations for older adults, 12 of which follow WHO. Thirteen countries also address at least one special population (eg, pregnant women, people with disabilities and people with chronic diseases), but the level of detail varies substantially between countries.

Conclusions: The large majority of EU Member States either has physical activity recommendations in place or is in the process of developing them. There is a general tendency to use the WHO Global Recommendations as a basis, with the greatest variation observable for children and adolescents. Comparing results with a previous round of data collection shows that the number of EU countries with physical activity recommendations is increasing and that both special groups and sedentary behaviour have become more important in recent years.
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http://dx.doi.org/10.1136/bmjopen-2019-034045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044960PMC
February 2020

The evolution of physical activity promotion. Are we entering a liquid age?

Glob Health Promot 2020 12 19;27(4):15-23. Epub 2019 Dec 19.

Friedrich-Alexander-Universität Erlangen-Nürnberg, Department of Sport Science and Sport, Erlangen, Germany.

In order to counteract risk factors for non-communicable diseases, promotion of physical activity has become increasingly relevant. This article outlines recent developments in this field, adopting a perspective based on Zygmunt Bauman's concepts of liquid modernity and liquid life. Five trends in physical activity promotion are identified: (Trend 1) The expansion of physical activity recommendations from a narrow focus on exercise to a broad concept of 24-h movement guidelines, (Trend 2) the increasing number of population groups targeted by these recommendations, (Trend 3) the ascent of efforts for physical activity promotion to the global level, (Trend 4) the emancipation of physical activity promotion from an add-on to a stand-alone public health topic, and (Trend 5) the ongoing conflict between sport, health and other sectors about the leading role in physical activity promotion. Based on these developments, physical activity might be classified as 'liquid' in Bauman's sense, that is, as being elusive and in a constant state of flux.
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http://dx.doi.org/10.1177/1757975919882381DOI Listing
December 2020

Nine types of recommendations, guidelines and policies: an exploratory test of a proposed typology of physical activity promotion documents.

Arch Public Health 2019 2;77:52. Epub 2019 Dec 2.

FAU Erlangen-Nürnberg, Department of Sport Science and Sport, Gebbertstraße 123b, 91058 Erlangen, Germany.

Background: The field of physical activity abounds with recommendations, guidelines, action plans and other documents published by experts, organizations and institutions at the national and international level. However, working with these documents is difficult since similar names (e.g. "recommendations") may be used to label substantially different contents, while identical topics may hide behind different monikers (e.g. "guidelines" and "strategy").

Methods: We built on an existing framework conceptualizing categories of physical activity evidence and on the Doern continuum for policy instruments to develop a nine-field matrix that classifies physical activity-related publications based on their evidence type and degree of coercion. We used a selection of eleven physical activity documents to perform an exploratory test of the functions and utility of the typology.

Results: Placing central physical activity documents into the typology shows that recommendations, guidelines, and policies are found across the entire matrix, regardless of their denomination. It also suggests that some documents transcend boundaries between types by falling into more than one category, and that some categories may be underrepresented in current physical activity promotion.

Conclusions: A typology to classify physical activity guidelines, recommendations, and policies can help us acquire a better overview of the landscape of existing physical activity documents than simple distinctions based on document names. It may guide both current initiatives and future development work in the field. It could also serve as a point of departure for future research, as conducting systematic overviews of the literature based on this typology may help reveal important gaps in current physical activity promotion.
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http://dx.doi.org/10.1186/s13690-019-0381-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6886183PMC
December 2019

Toward Whole-of-System Action to Promote Physical Activity: A Cross-Sectoral Analysis of Physical Activity Policy in Australia.

J Phys Act Health 2019 11 1;16(11):1029-1038. Epub 2019 Sep 1.

Background: The value of a systems thinking approach to tackling population physical inactivity is increasingly recognized. This study used conceptual systems thinking to develop a cognitive map for physical activity (PA) influences and intervention points, which informed a standardized approach to the coding and notation of PA-related policies in Australia.

Methods: Policies were identified through desktop searches and input from 33 nominated government representatives attending 2 national PA policy workshops. Documents were audited using predefined criteria spanning policy development, strategic approaches to PA, implementation processes, and evaluation. Data were analyzed using descriptive statistics.

Results: The audit included 110 policies, mainly led by the health or planning/infrastructure sectors (n = 54, 49%). Most policies purporting to promote PA did so as a cobenefit of another objective that was not focused on PA (n = 63, 57%). An intention to monitor progress was indicated in most (n = 94, 85%); however, fewer than half (n = 52, 47%) contained evaluable goals/actions relevant to PA. Descriptions of resourcing/funding arrangements were generally absent or lacked specific commitment (n = 67, 61%).

Conclusions: This study describes current PA-relevant policy in Australia and identifies opportunities for improving coordination, implementation, and evaluation to strengthen a whole-of-system and cross-agency approach to increasing population PA.
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http://dx.doi.org/10.1123/jpah.2019-0122DOI Listing
November 2019

Promoting health-enhancing physical activity in Europe: Current state of surveillance, policy development and implementation.

Health Policy 2018 05 3;122(5):519-527. Epub 2018 Feb 3.

World Health Organization, Regional Office for Europe, Division of Noncommunicable Diseases and Promoting Health through the Life-course; Copenhagen, Denmark.

This study aims to present information on the surveillance, policy developments, and implementation of physical activity policies in the 28 European Union (EU) countries. Data was collected on the implementation of the EU Recommendation on health-enhancing physical activity (HEPA) across sectors. In line with the monitoring framework proposed in the Recommendation, a questionnaire was designed to capture information on 23 physical activity indicators. Of the 27 EU countries that responded to the survey, 22 have implemented actions on more than 10 indicators, four countries have implemented more than 20 indicators, and one country has fully addressed and implemented all of the 23 indicators of the monitoring framework. The data collected under this HEPA monitoring framework provided, for the first time, an overview of the implementation of HEPA-related policies and actions at the national level throughout the EU. Areas that need more investment are the "Senior Citizens" sector followed by the "Work Environment", and the "Environment, Urban Planning, and Public Safety" sectors. This information also enabled comparison of the state of play of HEPA policy implementation between EU Member States and facilitated the exchange of good practices.
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http://dx.doi.org/10.1016/j.healthpol.2018.01.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5993869PMC
May 2018
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