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

in Journal of Physical Activity and Health

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.

As the global burden of noncommunicable disease continues to rise so does the importance of tackling physical inactivity which is a common and modifiable noncommunicable disease risk factor. Evidence about the contribution that inactivity makes to avoidable morbidity and mortality is well established,1 and the accumulated economic case for reducing this risk factor is also compelling.2,3 Yet, despite extensive international research efforts and the identification of an array of effective interventions,4,5 available trend data show that the prevalence of physical inactivity has mostly remained stable over the past 15 years worldwide,6 and over 22 years in Australia.7 National governments have been urged to prioritize this issue and commit to multifaceted policies and programs that address the socioecological determinants of inactivity.8,9 The World Health Organization’s Global Action Plan on Physical Activity (GAPPA)10 has stipulated 4 strategic objectives including “active societies,” “active environments,” “active people,” and “active systems,” while identifying explicit policy actions to guide the comprehensive approach required to tackle inactivity within populations.

The engagement of diverse sectors (such as health, sport, transport, and planning) has been identified as essential to delivering the broad scope of policy action required to address the multiple determinants of physical activity (PA).11 Although such a broad field for policy development offers substantial opportunities, it also holds potential risks, inherent within the challenge of achieving and maintaining a coordinated response across Australia’s federated system of independent national, state, and territory governments.12 Typically, these risks present themselves as uncoordinated policy actions, piecemeal planning, and patchy implementation. The necessary mitigation strategies involve strengthening communications across jurisdictions and forging a common strategic approach based on cross-sectoral partnerships that can enable the institutionalization of sustainable policy actions within the routine business of stakeholder organizations.13 Aspirations to achieve coordinated, embedded actions to address physical inactivity will be more likely to succeed if this issue is understood as a policy development task that has health and social implications, as well as political, organizational, economic, and cultural challenges.14

Systematic policy analysis studies have been conducted nationally and internationally to examine the nature, quality, and implementation of PA promotion policies and to identify factors requiring further attention. A study in Finland reported on the policies of different sectors (ie, health, education, and transport) that had enabled a shift from a primary focus on sports participation to a broader approach to health-enhancing PA and identified the political, social, and economic forces that contributed to this.15 Craig16 examined the evolution of PA policy in Canada and recognized the prominent role of provincial coalitions and multistrategic approaches, coupled with community development initiatives to support program delivery. One of the early comparative studies which presented case studies of PA policy in Switzerland, England, and Finland found differences attributable to cultural and political factors in each country and common barriers of resource limitations and competing priorities.17 Several other international studies have used structured audit tools to assess the characteristics and differences in PA-related policies across nations.1822 These generally observed cross-sectoral engagements in the development of PA policies but noted that there was scope for this to be broadened and better coordinated in policy implementation. A lack of measurable indicators and clear plans for policy evaluation was a commonly reported weakness.

The adoption of systems thinking to public health, together with the critical analysis of required strategic interventions, has increased the perceived need for the application of systems thinking to PA policy analysis and brought a fresh lens to guide how this is done. From a systems perspective, population levels of PA are an emergent product of the combined impact of multiple policies. At one level, this highlights the importance of understanding an operational whole-of-system approach to tackling physical inactivity,23 and at another level, it draws attention to questions of policy coordination, alignment, and interdependence.24,25 Recognizing the dynamic nature of the relationship between policies and their influence on PA, including the potential for feedback loops and systemic adaptations, a systems approach generates interest in strategic policy levers that will maximize change.26 Methodologically, it places value upon inductive, practice-based insights concerning the nature and operation of policy systems, which can be obtained through studies undertaken collaboratively by researchers and policymakers.27,28

“Australian Systems Approach to Physical Activity” is a national project that supports the development and alignment of policies, programs, and surveillance addressing PA at the population level. The first stage of this project is an audit and analysis of policies that promote PA across sectors and jurisdictions (state, territory, and federal) conducted with input from policymakers. Recognizing that there is a continuum of systems science applications from simple cognitive mapping through to more complex dynamic modeling,29,30 this study is located within the conceptual, systems thinking end of the systems science continuum (rather than the dynamic modeling end). This article reports the findings of the audit and reveals how PA has been addressed and embedded within the policies of different sectors and jurisdictions. Based on this, it is possible to determine the extent to which the broad mix of policy actions prescribed by GAPPA is in place in Australia. Furthermore, an examination of policy content, leadership, resourcing, governance, and monitoring allows identification of opportunities to strengthen the alignment, implementation, and impact of policies to address population physical inactivity.

Methods

Scope of Policies Included in Audit

Documents were included in the audit if they were policies relevant to PA. Policies were defined as written documents representing a commitment to a course of action, adopted by government or nongovernment agencies that contain goals/objectives, priorities, strategies, and/or actions for achieving those goals.19,22 Documents that did not meet this definition were excluded, which were mainly resources and guides. Policies that impact on population-level PA may be located in diverse sectors and may seek to specifically promote PA or more indirectly support PA by influencing the environments in which people work, commute, and spend their recreation time. For the purposes of this audit, policies were considered relevant to PA if they explicitly described an intent or recognized the potential of the policy to impact PA. To ascertain this, in-text searches were conducted for references to PA and related words such as “active,” “cycling,” “walking,” “walkable,” “sport,” “exercise,” “mobility,” “liveable,” and “chronic disease,” and then read for surrounding context to determine whether such intent or recognition was being expressed. Policies applying only to children and adults less than 18 years were excluded, as PA and related indicators for this age group are already monitored under a separate, policy informing initiative known as “Active Healthy Kids Australia.”31 As a result, education policies were largely excluded from this audit, although PA actions relevant to adults could still be addressed by other policies in the education domain (eg, by promoting shared use planning of education institutions and their sports or PA-related facilities or incorporating PA education into preservice training for medical professionals).

In Australia, a 3-tiered system of government applies, meaning that policies relating to PA may be developed at the national (federal), state (6 states and 2 territories) and local level (comprising over 500 local governments).32,33 For the purposes of this audit, the plethora of policies developed at the local government level were excluded to focus on policies with a regional or national focus. Policies developed at the state level but with only substate applicability were similarly excluded unless they covered a large metropolitan area, addressed multiple subregions, or were developed in accordance with an overarching policy (in which case, that overarching policy was audited). Other documents excluded were those that were in draft form, no longer current, or were classified as departmental strategic plans.

Identification of Documents

The process for the identification of PA-relevant policies comprised 3 stages: initial identification by government representatives at information gathering workshops, desktop searches, and a final verification and further identification of relevant documents by government representatives.

Stage 1: Initial Identification

Two workshops, each of 1 day’s duration, were held in May and August 2018 to elicit information from government agencies about PA-related policies and programs in their jurisdiction. Invitations to the workshops were extended to members of the National Physical Activity Network (an Australian PA policy alliance), senior public servants recognized as directly involved in PA policymaking, and (for the second workshop) advocates from major health-focused nongovernment organizations (NGOs). A total of 33 government representatives attended the workshops, representing each of the state, territory, and federal jurisdictions in Australia, and health (n = 14), sport (n = 12), and planning/transport (n = 7) sectors. Nine representatives from 8 NGOs attended the August workshop. Government representatives described and shared information about policies and large-scale programs relevant to PA that were applicable to adults 18 years and older and were in force within their jurisdictions in the last 5 years. This was through presentations delivered by the government representatives and an interactive, small groups exercise requiring participants to identify and map the current policy actions and programs to promote population PA in their jurisdictions, against the 8 domains comprising the “7 Best Investments for Physical Activity”34 and the workplace setting.35 Documents identified from the workshops were collated into a spreadsheet, and Internet searches conducted to locate copies of the target documents. Where a document could not be located, it was recorded and noted for follow-up under Stage 3. Websites of represented NGOs were also reviewed for PA-relevant policies. NGO policies were included in the audit if they were formally adopted by the NGO (as opposed to providing a blueprint for others, or designed to be an advocacy tool), and the NGO had resources to implement the policy actions proposed.

Stage 2: Desktop Searches

Other potentially relevant policies were identified based on other documents named in PA-relevant government policies from Stage 1 as forming part of their policy context, the Appendices of a recent report mapping transport, planning, and infrastructure policies against liveability domains in 4 Australian states36; recent commentary reporting on developments in healthy planning policy in New South Wales37; and the database of PA policies relevant to Aboriginal Australians located at HealthInfoNet.38 Internet searches were conducted to locate copies of these policies, and a record kept of those documents unable to be located that appeared to be PA-relevant. Where other policies were discovered incidentally in the process of conducting these searches, they were also considered for inclusion. Additional keyword Internet searches were conducted in policy areas or for subject matter that could reasonably be expected to address PA (eg, searches for state and territory level sport and active recreation plans were prompted by the existence of a national framework39 requiring each state and territory jurisdiction to develop such plans; searches for infrastructure-related policies in some jurisdictions were prompted by the existence of PA-relevant infrastructure policies in other jurisdictions, similar searches for policies specific to particular subpopulation groups such as those with a disability, older people, and women were prompted by the identification of PA-relevant policies for these groups in some jurisdictions). Keyword searches generally comprised searching the name of a particular state and territory jurisdiction and relevant keywords. (In relation to the previously mentioned examples, these included keywords such as “sport and active recreation plan,” “infrastructure strategy,” and “disability/ageing/women strategy.”) Statutory instruments were excluded from consideration in Stage 2.

Stage 3: Consolidation and Validation

All PA-relevant policies identified from Stages 1 to 2 were consolidated for each jurisdiction and mapped against the policy areas of health, transport, environment, sport, planning/infrastructure, education, priority groups, and other. In August 2018, government representatives from the workshops were e-mailed a copy of the spreadsheet and requested to review the list of policies that had been included for their jurisdiction and to identify any other policies relevant to PA, seeking the advice of other government departments where necessary. These representatives were also asked to supply a copy of those documents, which could not be located using Internet searches, or to otherwise advise on their status. Responses from all jurisdictions were received by October 2018.

Audit Process

An audit tool was developed to identify policy content in a systematic and consistent manner according to a defined set of criteria. Criteria were based on elements identified as relevant for effective PA or public health-related policy19,34,40,41 and aimed to inform an overall understanding of the current PA policy landscape in Australia with regard to the broad mix of themes and actions in GAPPA.10 The tool comprised general criteria relating to the policy overall, and more specific criteria relating to the PA-relevant components (Supplementary Table 1 [available online]). Audit fields and categories were refined through discussion across the authors to resolve ambiguities in application of the tool, and the modified criteria were reapplied to documents already audited. The policy audit was primarily conducted by TN and KL. Where related documents were available in direct connection with the primary document (eg, an action plan or monitoring framework), these documents were analyzed along with the parent document as 1 policy. When assessing the agencies involved in policy development, documents developed vertically (ie, by agencies from the same sector but across different levels of government) or between a state government department and local government were categorized as “other” rather than “whole-of-government.” An interrater agreement exercise was undertaken to determine percentage agreement42 in respect of the policy domain and policy mechanism fields for a sample of 40 documents selected to represent a range of jurisdictions and sector leads. Interrater agreement was 80% for the policy domain fields and 82% for the mechanism fields. Audit data were analyzed using IBM SPSS Statistics (version 24; IBM Corporation, Armonk, NY).

Results

Overview of Included Documents

A summary of documents identified and screened for the policy mapping audit is presented in Figure 1. Overall, 110 documents were included as PA-relevant policies, and 48 were excluded for reasons shown. Table 1 presents that most of these policies were developed at the state or territory level (n = 94, 86%), noting that this comprises 8 jurisdictions and local government policies were excluded from this audit. Most policies specified a time frame of 3 or more years (n = 72, 65%), although 31% (n = 34) failed to specify a time frame. Based on their stated goals and strategies, most policies (n = 75, 68%) were aimed primarily at the whole-of-population level and targeted general health and well-being (n = 93, 85%), with few dedicated to specific subgroups or particular chronic conditions (Table 1). Although all documents included in the audit were “policies” for the purposes of this study, few used the word “policy” in their title (n = 8, 7%), with other documents variously labeled as a “plan” (n = 37, 34%); “strategy” (n = 36, 33%); or “framework” (n = 20, 18%).

Figure 1
Figure 1

—Overview of documents identified and screened. PA indicates physical activity.

Citation: Journal of Physical Activity and Health 16, 11; 10.1123/jpah.2019-0122

Table 1

Overview of Documents Included in Audit Analysis (N = 110)

N%
Policy level
 Federal1312
 State or territory9486
 Organization33
Duration
 Up to 3 y44
 3–5 y3229
 More than 5 y4036
 No time frame specified3431
Primary target group
 Whole-of-population7568
 People with a disability109
 Women98
 Aboriginal76
 Older adults44
 Other55
Primary target condition
 General health and wellbeing9385
 Overweight and obesity22
 Specific chronic condition76
 Other87
Agencies involved
 Single agency4541
 Whole-of-government (with lead agency)3532
 Whole-of-government (without lead agency)98
 Two to four agencies76
 Othera1413
Sector lead
 Health3027
 Planning/infrastructure2422
 Transport1413
 Sport1110
 Cross-sectoral (no identifiable lead)109
 Community services98
 Environment66
 NGO33
 Other22
 Private11

Abbreviation: NGO, nongovernment organization.

aWhere policies were developed by agencies from the same sector across different levels of government, this was classified as “Other” rather than “Whole-of-government.”

Policy Development

Table 2 presents the main sectors involved and coordination/leadership approaches used in the development of PA-relevant policy. Many documents (n = 45, 41%) were developed by a single agency, although a cross-agency or whole-of-government approach was apparent in 46% of documents (n = 51). The health sector led the development of the greatest number of PA-relevant policies (n = 30, 27%) followed by the planning/infrastructure sector (n = 24, 22%).

Table 2

PA Policy Domains and Mechanisms (N = 110)

N%
PA policy domains
 Domains addressed
  Urban design and infrastructure6761
  Transport and environment5853
  Sport and recreation4844
  Community-wide program3633
  Mass media and public education3431
  Workplace2826
  Primary and secondary health care2624
  Education1816
 No. of domains covered
  0–12926
  2–34642
  4 or more3532
PA mechanisms
 Mechanisms described or apparent
  Communication or policy disseminationa8981
  Organization or coordinationb5954
  Infrastructure or service delivery4642
  Fiscal measuresc3330
  Industry regulation2523
  Industry quality standardsd2119
  Procurement standardse55
  Registration, certification, or licensing11
  Marketing, advertising, or sponsorship standards00
 No. of mechanisms
  0–13027
  2–35651
  4 or more2422

Abbreviation: PA, physical activity.

a“Communication or policy dissemination” included community education and awareness raising initiatives and dissemination of guidance for implementation by other policymakers/practitioners. b“Organization and coordination” included development of collaborative mechanisms and capacity building of external stakeholders. c“Fiscal measures” included funding/investment schemes and tax incentives. dUnlike “industry regulation”, “industry quality standards” were not legally enforceable and included development and incorporation of best practice guidelines or principles. e“Procurement standards” included gender targets for equality in governance in sport and recreation organizations.

Approaches to Addressing PA

As presented in Table 3, a small proportion of documents (n = 17, 16%) included a primary objective with a specific focus on increasing PA (eg, to be the most active state), which was mainly the case in policies led by the sport sector. Most policies facilitated PA as a cobenefit of achieving another objective that was not focused on PA (n = 63, 57%) (eg, to enhance liveability and to achieve a safer road system), which was mainly evident in planning, environment, and transport sector-led policies. PA was a contributory factor toward achieving the policy’s primary objective in the remaining documents (n = 30, 27%) (eg, to prevent obesity and to reduce cardiovascular morbidity and mortality), which was mainly the case in health sector-led policies. Very few defined PA (n = 3, 3%) or referred to the national guidelines on PA (n = 19, 17%).

Table 3

Description of Resourcing Commitment

NNone specified, N (%)General statement of intent, N (%)Commitment to fund policya (not PA specific), N (%)Commitment to fund PA components, N (%)
All policies11036 (33)31 (28)15 (14)28 (26)
Relationship of PA to primary objectives
 Primary objective179 (53)2 (12)06 (35)
 Contributory factor309 (30)11 (37)5 (17)5 (17)
 Facilitated through primary objective6318 (29)18 (29)10 (16)17 (27)
Sector lead
 Health309 (30)12 (40)4 (13)5 (17)
 Sport114 (36)3 (27)04 (36)
 Transport141 (7)4 (29)3 (21)6 (43)
 Planning247 (29)7 (29)1 (4)9 (38)
 Environment62 (33)2 (33)2 (33)0
 Community96 (67)1 (11)1 (11)1 (11)
 Cross-sectoral (no clear lead)104 (40)1 (10)4 (40)1 (10)
 NGO32 (67)1 (33)00
 Private10001 (100)

Abbreviations: NGO, nongovernment organization; PA, physical activity.

aA commitment to funding was generally considered to be demonstrated if a monetary amount was allocated to one or more of the policy actions, an amount had been budgeted for overall policy implementation, the policy contained actions to procure funding, or reference was made to preexisting funding arrangements or sources.

The target groups of PA-relevant policy actions were mainly providers (eg, other policymakers, clinicians, and practitioners) (n = 96, 87%) and the general population (and/or a specific subgroup) (n = 81, 74%). Forty-six documents contained PA-relevant policy actions aimed at one or more population subgroups, such as Aboriginal populations, those with a disability, older adults, and women. Fewer documents contained PA-relevant actions aimed at individuals/families (n = 23, 21%) and peak bodies (representative agencies for members with allied interests, such as advocacy groups, industry bodies, and sporting or professional associations) (n = 40, 36%).

Physical activity-relevant policy actions were classified according to which of 8 PA policy domains they addressed. Domains were derived from the “7 Best Investments for Physical Activity” identified by the International Society for Physical Activity and Health,34 and from the GAPPA,10 and included the workplace setting in recognition of the evidence supporting its inclusion as an additional policy domain.35 As presented in Table 2, the policy domains most commonly included within our classification were urban design and infrastructure, and transport and environment, with over 50% of policies addressing either or both of these domains. The least frequently addressed domains were workplace, primary and secondary health care, and education. Most of the policies directed at the primary and secondary health care domain were led by the health sector (n = 20; 77%), with few policies led outside the health-sector contributing to this domain. In contrast, the main contributors to the urban design and infrastructure domain included policies that were led by the planning and infrastructure sector (n = 24, 36%), as well as other sectors such as transport (n = 14, 21%) and health (n = 10, 15%). Other key domains addressed in policies led by the health sector included mass media and public education (n = 17, 57%); workplaces (n = 14, 47%); and community-wide programs (n = 14, 47%). PA-relevant actions were classified according to the underlying mechanisms for their implementation but could not be discerned in some instances due to imprecise descriptors (eg, “develop and implement actions to address racism in sport and recreation,” and “develop and support opportunities for sport and recreation”) or because they were framed as scoping measures (eg, “investigate and consider fiscal policies with the potential to remove barriers to participation,” and “review existing fare structure to make public transport more convenient”), or as broad strategic directions. Examples are provided in Supplementary Table 2 (available online) to illustrate the types of actions described by documents, which were regarded as addressing particular domains or using certain mechanisms. Supplementary Table 3 (available online) contains examples of PA-relevant policies in Australia, mapped against the GAPPA actions and the key domains to which they relate. It has been supplemented with additional examples of programs, including those applicable to children and young adults less than 18 years, as identified from the 2018 Active Healthy Kids Report Card31 and PA programs identified by stakeholders at the national workshops.

Implementation and Evaluation

Shared responsibility, such as where lead and partner agencies were specified, was the most commonly identified approach to implementation (n = 45, 41%; Table 4). Where implementation was broadly described as “shared” without delineating specific responsibilities, this was classified as “none specified.” Adequate delineation of responsibility for the PA-relevant goals or actions of the policy was noted in 63% of audited documents.

Table 4

Overview of Implementation and Evaluation Approaches (N = 110)

N%
Allocation of responsibility
 For the document overall
  Shared responsibility4541
  Lead agency2422
  Nominated position33
  Other87
  None specifieda3027
 Responsibility specified for PA components
  Yes6963
  No4137
Coordination mechanisms
 Independent governance committeeb55
 Governance committee3431
 Otherc2220
 None specified4945
Monitoring mechanisms specifiedd
 Monitoring framework8375
 Regulatory enforceability98
 Other22
 None specified1615
Evaluability of PA goals/actionse
 Yes5247
 No5853

Abbreviation: PA, physical activity.

aWhere implementation was described as “shared” or by the “Government” without delineating responsibilities of specific agencies, sectors, or levels of government, this was classified as “none.” bGovernance committees were regarded as independent if they were only comprised of external (ie, nongovernment) stakeholders or were established as an independent body. c“Other” included where coordination was by an existing department (eg, the lead agency and Department of Premiers and Cabinet) or if the independent or nonindependent nature of the coordinating body could not be determined from publicly available information. dIndications of an intention to monitor and/or report on progress was sufficient to amount to specification of monitoring mechanisms. eGoals/actions were determined to be evaluable if described with sufficient specificity to render them amenable to evaluation or where intended data sources/tools for evaluation were referenced.

Over half of the documents described some form of coordination body for implementation and/or monitoring, with functions such as providing oversight, advice, support, and/or leadership. The most common of these arrangements was a governance committee (n = 34, 31%), membership of which was generally described as including cross-agency representation and in some cases also representation among external stakeholders (eg, peak bodies, NGOs, private sector, and community members). Few documents described independent governance committees, where governance was through nongovernment stakeholders or a body with statutory independence (n = 5, 5%).

Most documents indicated some form of commitment or intention to monitor and/or report on the progress of implementation and/or outcomes (Table 4). Although in many cases, the processes for monitoring were still to be developed or were not described in detail. Verification of the implementation of intended monitoring processes was out of scope for this project. Eleven documents were regarded as having regulatory enforceability (eg, where monitoring, implementation, and/or reporting were or are mandated by governing legislation).

Documents were assessed for the evaluability of their PA-relevant goals or actions. Goals/actions were determined to be evaluable if they were described with sufficient specificity to render them amenable to evaluation. This could be established by referencing relevant data sources or indicators even if those indicators did not specify the desired direction of change or target. Examples of evaluable goals/actions included those which referenced indicators such as the proportion of adults who are sufficiently physically active; increases in the number, frequency, and diversity of people cycling for transport; and percentage of the population living within 30 minutes by public transport of a city or major metropolitan center. Less than half of the documents were considered to contain evaluable PA-relevant goals/actions (Table 4). Goals/actions that were not considered evaluable included those where indicators were still to be developed or were not publicly available or provided for review, indicators that were not specific to the policy but referenced those of other policies toward which the policy was intended to contribute, or those that only contained implementation indicators without any associated reach and/or impact or outcome measures.

The majority of policies (n = 67, 61%; Table 3) did not describe any resourcing or funding arrangements or only expressed a general statement of intent to resource the policy, such as by using wording to the following effect: “investment decisions will be guided by policy priorities,” “financial commitment will be commensurate with need,” “implementation will occur within the agency’s resource capability,” and “funding allocation will be the subject of further analysis and budgetary consideration.” A commitment to funding was expressed if, for example, a dollar amount was allocated to one or more of the policy actions, an amount had been budgeted for implementation of the policy overall, the policy contained actions to procure funding, or reference was made to preexisting arrangements or sources for funding. The sustainability, availability, or sufficiency of funding for the duration of the policy or implementation of policy actions was not ascertained.

Table 3 presents the level of resourcing commitment described by policies, according to the relationship of the policy’s primary objectives to PA, and by the type of sector leading development of that policy. The findings indicate a general lack of consideration or explicit commitment to funding/resourcing, across sectors regardless of the importance of PA to the document in terms of its relationship to the policy’s primary objectives. Notably, 11 out of 17 policies which had a primary objective of increasing PA either did not describe any resourcing or funding or only expressed a general statement of intent to resource the policy (Table 3). Most of the policies led by the key sectors for PA-relevant policy development (Table 1) also lacked express consideration of/or commitment to funding/resourcing (Table 3).

Discussion

The Global Action Plan on Physical Activity calls for jurisdictions worldwide to employ a coordinated, whole-of-system approach to ensure effective implementation of its recommended actions at national and subnational levels.10 In Australia, no formal national policy framework or governance system currently exists to coordinate a comprehensive approach to PA. A considerable challenge to achieving the desired outcomes in Australia (and countries such as Canada and Germany) is its federated government structure which comprises separate central and regional governments. It is perhaps revealing of the nature of this challenge that few policies in this audit (while relevant to PA) referred to the national guidelines on PA which have been in place since 2014. Nonetheless, and despite the fact that most policies in this audit predated the release of GAPPA, this study found indications of cross-sectoral approaches to developing PA-relevant policy at state/territory and federal levels, and consideration of multistrategic policy interventions (addressing multiple domains and/or mechanisms) that are consistent with criteria for successful PA policy.18,20,43 These findings suggests a level of appreciation across jurisdictions and sectors about some of the cobenefits associated with addressing PA within other agendas, and existing linkages can be leveraged to develop the comprehensive and integrated approach to PA that is essential for impactful policy development and implementation.

Perhaps the clearest sign of the integration of PA into the policies of other sectors is in relation to the built environment. Evidence of this is shown by the leadership demonstrated by the planning and transport sectors in developing PA-relevant policy, coverage of “urban design and infrastructure” and “transport and environment” as key policy domains and use of infrastructure/service delivery as one of the main policy mechanisms. These provide positive indications of a policy focus geared toward supporting active environments, which is one of the core components of GAPPA10 and an important means to achieving scale in PA interventions and population reach.4446 Analyses conducted internationally have similarly revealed evidence of integration of PA into multiple agendas such as education, sport, and health but more limited evidence of integration in the areas of transport and urban planning.19,20,47 The prominence of supportive PA policy in the transport and urban planning domains in Australia can be attributed to developments over the course of more than a decade, which has seen the emergence of a common agenda and language that has appeared to resonate with these sectors, supported by partnerships with the health sector, a growing evidence base, and advocacy and capacity building efforts by the National Heart Foundation to promote the integration of active living principles in planning and transport policy.48

Despite these promising developments, a major uncertainty lies in the degree to which many of the identified PA-relevant policies are truly being implemented. Fundamental criteria for successful policy implementation include adequate resourcing, clear delineation of roles and responsibilities, and independent evaluation.18,49 The importance of securing financing for sustained implementation is highlighted in GAPPA as one of the recommended actions for developing “active systems.10” However, previous analyses have consistently revealed a lack of express resource allocation for PA-relevant policy.18,19,47 Similar shortcomings were found in this audit, with almost two-thirds lacking a clear commitment to funding. Where included, coordination structures for governance or oversight over implementation and/or monitoring were rarely independent. In addition, it was not always clear how PA-relevant actions were to be implemented or evaluated, with most policies lacking in specific indicators or data sources to support their evaluation; a limitation that has also been found in previously conducted international policy assessments.19,20

Across policies, the dominant mechanism for the achievement of PA-relevant objectives was informational in nature, for example, through public education and awareness raising or through communication of guidance to assist policymakers and other providers. Although most policies described the use of 2 or more mechanisms, there is scope for policymakers to use a wider range of mechanisms consistent with recommended approaches for addressing other public health concerns such as obesity and unhealthy eating.41,44 Given the limited effectiveness of information-only approaches for increasing population PA,50 a wide range of mechanisms is likely to be needed to promote PA for different population groups and stages of change of behavior, which may also help to maximize the synergistic impact of interventions (eg, fiscal incentives to promote use of new active transport infrastructure may also improve uptake among those exposed to public education and awareness raising).51 Efforts to achieve greater breadth in the range of implementation mechanisms adopted may need to be underpinned by extensive prior dissemination of evidence about the impact or efficacy of different policy actions on PA and how they can be combined for optimal effects.45

Other potential opportunities for improvement can be seen in the degree of attention given in policies to support activity among adults in key settings that include health care, workplace, and education. This is closely aligned with the “active people” objective of GAPPA.10 Under this objective, actions are recommended to support activity among adults in key settings that include health care, workplace, and education.10 Health care and workplaces were among the least addressed domains in this audit (education policies being largely excluded due to the focus on adult-related policies), which suggests scope for further actions consistent with GAPPA, and International Society for Physical Activity and Health’s “7 Best Investments” combined with the evidence supporting the workplace setting as an additional policy domain.10,34,35 GAPPA also emphasizes the need for focused efforts to improve PA among specific groups identified as being less active.10 In this audit, most policies were primarily aimed at the whole-of-population level, with few stand-alone policies for priority groups such as Aboriginal Australians and older adults. Although initial efforts at policy development are appropriately conceptualized on a whole-of-population level to shift population level of activity,47 there is a risk of widening inequalities in the absence of targeted strategies (consistent with principles of proportional universality) to promote PA among inactive subgroups, particularly those who are socially disadvantaged.10,47,52

A systems approach to PA considers not only the breadth and mix of policies, but also the interactions between them which may reinforce or attenuate actions in different parts of the system and across the system as a whole.53 A comprehensive understanding of all agencies, their interrelationships, and how their interactions can support a policy system for PA is therefore necessary, which could be facilitated by the creation of a national governance group with an imprimatur for cross-sectoral coordination and supported by a cross-jurisdictional communications network together with measures to ensure effective policy governance, coordination, and accountability.8,13 Internationally, some countries have developed national PA strategies that pursue the PA agenda in concert with other policies across sectors (eg, England’s “Everybody Active, Every Day”54 and Finland’s “On the Move National Strategy for Physical Activity Promoting Health and Wellbeing 2020”55). In Australia, there are historical precedents of state-based PA frameworks and task forces/multisector coalitions that may provide models for the development of a national framework and coordination structure (eg, NSW’s “Simply active everyday: A plan to promote physical activity in NSW 1998–2002,” which was led by the NSW Physical Activity Task Force; and WA’s “Active Living for All: A Framework for Physical Activity” led by the WA Physical Activity Taskforce56). Australia’s federal system also lends itself to various cooperative arrangements that may be suitable for facilitating whole-of-government action on PA (eg, cooperative legislative schemes, framework laws, intergovernmental arrangements, and ministerial councils),32 some of which were evident from the audit as being employed to support nationwide coordinated action on issues such as disability and road safety. By building on the lessons learned from past experiences and harnessing the existing capabilities and linkages within the PA system, a national strategy (properly resourced and governed) could accelerate Australia’s progress toward a stronger, whole-of-system approach to increasing PA in the population.18,44,47,57 It is important to emphasize the need for proper resourcing and governance to support the success of a whole-of-system approach to PA; cross-government, intersectoral action alone (even with the selection of the right suite of policy actions) will not be sufficient to prevent the common types of strategic failure that have impeded progress toward addressing PA and obesity in Australia and around the world.49,58 The existence of a cross-government policy platform (eg, an intergovernmental committee or task force on PA) is a positive step, but it does not guarantee meeting the criteria for effective policy governance49 or consider what a whole-of-system perspective in that governance implies.59

This study has some limitations. Due to the existing, policy informing work of Active Healthy Kids Australia,31 policies that were not applicable to adults were intentionally excluded, meaning that education policies were largely absent from this audit. Local government documents were also outside of scope, although an audit previously conducted by one Australian jurisdiction of their local government policies in respect of active living60 demonstrated the potential value of local community efforts to support PA. In addition, while relevant legislation and other statutory instruments were included in the audit if they were specified by the jurisdictional representatives, desktop searches were not undertaken to obtain a more comprehensive capture. Further identification and analysis of relevant legislation (eg, planning regulations) may be of value in future research. Other policies were not captured because they did not specifically mention PA, although they may still be relevant to PA. For example, while many jurisdictions have adopted a road safety policy incorporating safe systems principles which help support active environments,10 not all specifically referred to PA. Policies and policy actions that undermine PA or promote inactivity were also outside the scope of this review. Finally, our analysis was limited to policies in force at the time of completing the final phase of identifying relevant documents for this audit (ie, August to October 2018) and a review of policy content. It is possible that some of the limitations identified in this audit are being addressed in new or updated policies that are not yet available and that some steps relating to evaluation and funding of PA policy actions are occurring in practice notwithstanding a lack of detail in policy documentation.

Conclusions

This study reveals a level of awareness about, and appreciation of, the relevance and importance of addressing PA within the policy agendas of multiple sectors. Encouragingly, it has found substantial evidence of policies that align with the “active environments” objective in GAPPA; however, it identified fewer examples of policy addressing the “active people” objective, particularly in relation to high needs groups and PA promotion through health care and workplace settings. The analysis highlights areas of policy governance, coordination, financing, and evaluation that need strengthening, which shows there is considerable progress yet to be made in relation to the “active system” objective of GAPPA. Notwithstanding the challenges inherent in Australia’s federated structure of government, it is essential to be working toward an integrated, whole-of-system approach to increasing PA. This study presents an example of policy research that can guide these efforts to support the strategic, cross-sectoral action required to meet the global targets adopted by Australia to achieve a 15% reduction in population levels of physical inactivity by 2030.

Acknowledgments

Funding for this research has been provided from the Australian Government’s Medical Research Future Fund (MRFF). The MRFF provides funding to support health and medical research and innovation, with the objective of improving the health and well-being of Australians. MRFF funding has been provided to The Australian Prevention Partnership Centre under the MRFF Boosting Preventive Health Research Program. Further information on the MRFF is available at www.health.gov.au/mrff. The authors acknowledge the contributions of Lilian Chan (Prevention Research Collaboration, Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia) who assisted with the audit of the policy documents, and the participants of the two workshops who provided information in relation to relevant policy documents.

References

  • 1.

    Lee IM, Shiroma EJ, Lobelo F, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219–229. PubMed ID: 22818936 doi:10.1016/S0140-6736(12)61031-9

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Ding D, Lawson KD, Kolbe-Alexander TL, et al. The economic burden of physical inactivity: a global analysis of major non-communicable diseases. Lancet. 2016;388(10051):1311–1324. PubMed ID: 27475266 doi:10.1016/S0140-6736(16)30383-X

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Cadilhac DA, Cumming TB, Sheppard L, Pearce DC, Carter R, Magnus A. The economic benefits of reducing physical inactivity: an Australian example. Int J Behav Nutr Phys Act. 2011;8(1):99. doi:10.1186/1479-5868-8-99

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Heath G. Evidence-based intervention in physical activity: lessons from around the world. Lancet. 2012;380:272–281. PubMed ID: 22818939 doi:10.1016/S0140-6736(12)60816-2

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Varela AR, Pratt M, Powell K, et al. Worldwide surveillance, policy, and research on physical activity and health: the global observatory for physical activity. J Phys Act Health. 2017;14(9):701–709. PubMed ID: 28513338 doi:10.1123/jpah.2016-0626

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1.9 million participants. Lancet Glob Health. 2018;6(10):e1077–1086. doi:10.1016/S2214-109X(18)30357-7

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Chau J, Chey T, Burks-Young S, Engelen L, Bauman A. Trends in prevalence of leisure time physical activity and inactivity: results from Australian National Health Surveys 1989 to 2011. Aust N Z J Public Health. 2017;41(6):617–624. PubMed ID: 28749561 doi:10.1111/1753-6405.12699

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Kohl HW, Craig CL, Lambert EV, et al. The pandemic of physical inactivity: global action for public health. Lancet. 2012;380(9838):294–305. PubMed ID: 22818941 doi:10.1016/S0140-6736(12)60898-8

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    World Cancer Research Fund (WCRF)/American Institute for Cancer Research. Continuous Update Project Expert Report 2018. Recommendations and Public Health and Policy Implications. London, UK: WCRF; 2018. dietandcancerreport.org. Accessed January 15, 2019.

    • Search Google Scholar
    • Export Citation
  • 10.

    World Health Organization (WHO). Global Action Plan on Physical Activity 2018–2030: More Active People for a Healthier World. Geneva, Switzerland: WHO; 2018. https://www.who.int/ncds/prevention/physical-activity/global-action-plan-2018-2030/en/. Accessed November 21, 2019.

    • Search Google Scholar
    • Export Citation
  • 11.

    Rutter H, Cavill N, Bauman A, Bull F. Systems approaches to global and national physical activity plans. Bull World Health Organ. 2019;97:162–165. https://www.who.int/bulletin/volumes/97/2/18-220533/en/. Accessed January 15, 2019.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Bennett S. The Politics of the Australian Federal System—Research Brief No. 4. Canberra, Australia: Department of Parliamentary Services; 2006. https://www.aph.gov.au/binaries/library/pubs/rb/2006-07/07rb04.pdf. Accessed February 6, 2019.

    • Search Google Scholar
    • Export Citation
  • 13.

    Bellew B, Bauman A, Martin B, Bull F, Matsudo V. Public policy actions needed to promote physical activity. Curr Cardiovasc Risk Rep. 2011;5(4):340. doi:10.1007/s12170-011-0180-6

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14.

    Rütten A, Abu-Omar K, Gelius P, Schow D. Physical inactivity as a policy problem: applying a concept from policy analysis to a public health issue. Health Res Policy Syst. 2013;11(1):9. doi:10.1186/1478-4505-11-9

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Vuori I, Lankenau B, Pratt M. Physical activity policy and program development: the experience in Finland. Public Health Rep. 2004;119(3):331–345. PubMed ID: 15158112 doi:10.1016/j.phr.2004.04.012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Craig CL. Evolution and devolution of national physical activity policy in Canada. J Phys Act Health. 2011;8(8):1044–1056. PubMed ID: 22039123 doi:10.1123/jpah.8.8.1044

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Cavill N, Foster C, Oja P, Martin BW. An evidence-based approach to physical activity promotion and policy development in Europe: contrasting case studies. Promot Educ. 2006;13(2):104–111. PubMed ID: 17017287 doi:10.1177/10253823060130020104

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Bellew B, Schöeppe S, Bull FC, Bauman A. The rise and fall of Australian physical activity policy 1996-2006: a national review framed in an international context. Aust New Zealand Health Policy. 2008;5(1):18. doi:10.1186/1743-8462-5-18

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19.

    Daugbjerg SB, Kahlmeier S, Racioppi F, et al. Promotion of physical activity in the European region: content analysis of 27 National Policy Documents. J Phys Act Health. 2009;6(6):805–817. PubMed ID: 20101924 doi:10.1123/jpah.6.6.805

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Bull FC, Milton K, Kahlmeier S. National policy on physical activity: the development of a policy audit tool. J Phys Act Health. 2014;11(2):233–240. PubMed ID: 23364305 doi:10.1123/jpah.2012-0083

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Bull FC, Milton K, Kahlmeier S, et al. Turning the tide: national policy approaches to increasing physical activity in seven European countries. Br J Sport Med. 2015;49:749–756. doi:10.1136/bjsports-2013-093200

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22.

    Christiansen NV, Kahlmeier S, Racioppi F. Sport promotion policies in the European Union: results of a contents analysis. Scand J Med Sci Sports. 2014;24(2):428–438. PubMed ID: 22943209 doi:10.1111/j.1600-0838.2012.01500.x

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Bagnall A-M, Radley D, Jones R, et al. Whole systems approaches to obesity and other complex public health challenges: a systematic review. BMC Public Health. 2019;19(1):8. PubMed ID: 30606173 doi:10.1186/s12889-018-6274-z

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Rutter H, Savona N, Glonti K, et al. The need for a complex systems model of evidence for public health. Lancet. 2017;390(10112):2602–2604. PubMed ID: 28622953 doi:10.1016/S0140-6736(17)31267-9

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Wutzke S, Morrice E, Benton M, Wilson A. Systems approaches for chronic disease prevention: sound logic and empirical evidence, but is this view shared outside of academia. Public Health Res Pract. 2016;26(3):e2631632. doi:10.17061/phrp2631632

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26.

    Vandenbroeck P, Goossens J, Clemens M. Foresight Tackling Obesities: Future Choices—Building the Obesity System Map. London, UK: Government Office for Science; 2007. https://www.gov.uk/government/publications/reducing-obesity-obesity-system-map. Accessed January 15, 2019.

    • Search Google Scholar
    • Export Citation
  • 27.

    Green LW. Public health asks of systems science: to advance our evidence-based practice, can you help us get more practice-based evidence? Am J Public Health. 2006;96(3):406–409. PubMed ID: 16449580 doi:10.2105/AJPH.2005.066035

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Freebairn L, Rychetnik L, Atkinson J-A, et al. Knowledge mobilisation for policy development: implementing systems approaches through participatory dynamic simulation modelling. Health Res Policy and Syst. 2017;15(1):83. doi:10.1186/s12961-017-0245-1

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29.

    Elsawah S, Guillaume JHA, Filatova T, Rook J, Jakeman AJ. A methodology for eliciting, representing, and analysing stakeholder knowledge for decision making on complex socio-ecological systems: from cognitive maps to agent-based models. J Environ Manage. 2015;151:500–516. PubMed ID: 25622296 doi:10.1016/j.jenvman.2014.11.028

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Voinov A, Jenni K, Gray S, et al. Tools and methods in participatory modeling: selecting the right tool for the job. Environ Model Softw. 2018;109:232–255. doi:10.1016/j.envsoft.2018.08.028

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 31.

    Active Healthy Kids Australia. Muscular Fitness: It’s Time for a Jump Start. The 2018 Active Healthy Kids Australia Report Card on Physical Activity for Children and Young People. http://www.activehealthykidsaustralia.com.au. 2018; Accessed May 17, 2019.

    • Search Google Scholar
    • Export Citation
  • 32.

    Twomey A, Withers G. Federalist Paper 1 Australia’s Federal Future: Delivering Growth and Prosperity. Melbourne, Victoria: Dept of Premier and Cabinet; 2007. Accessed December 18, 2018.

    • Search Google Scholar
    • Export Citation
  • 33.

    Australian Statistical Geography Standard (ASGS). Volume 3—Non ABS Structures. Australian Bureau of Statistics Website; 2016. http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/1270.0.55.003~July%202016~Main%20Features~Local%20Government%20Areas%20(LGA)~7. Accessed February 7 2019.

    • Search Google Scholar
    • Export Citation
  • 34.

    Global Advocacy for Physical Activity (GAPA) the Advocacy Council of the International Society for Physical Activity and Health (ISPAH). NCD prevention: investments that work for physical activity. Br J Sports Med. 2012;46(8):709–712. doi:10.1136/bjsm.2012.091485

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Bellew B. Managing Health and Wellbeing in the Workplace: An Evidence Check Rapid Review Brokered by the Sax Institute for SafeWork NSW. 2018. https://www.saxinstitute.org.au/publications/managing-health-wellbeing-workplace/. Accessed January 23, 2019.

    • Search Google Scholar
    • Export Citation
  • 36.

    Arundel J, Lowe M, Hooper P, et al. Creating Liveable Cities in Australia. Mapping Urban Policy Implementation and Evidence-Based National Liveability Indicators. Melbourne, Australia: Centre for Urban Research (CUR) RMIT University; 2017.

    • Search Google Scholar
    • Export Citation
  • 37.

    Harris P, Harris E, Riley E, Kent J, Sainsbury P. With health assuming its rightful place in planning, here are 3 key lessons from NSW. In: The Conversation; 2018. https://theconversation.com/with-health-assuming-its-rightful-place-in-planning-here-are-3-key-lessons-from-nsw-94171. Accessed December 18, 2018.

    • Search Google Scholar
    • Export Citation
  • 38.

    Edith Cowan University. Australian Indigenous HealthInfoNet. https://healthinfonet.ecu.edu.au. Accessed August 24 2018.

  • 39.

    Commonwealth of Australia. National Sport and Active Recreation Policy Framework. Canberra, Australia: Commonwealth of Australia; 2011. http://www.health.gov.au/internet/main/publishing.nsf/Content/nsarpf. Accessed February 22, 2019.

    • Search Google Scholar
    • Export Citation
  • 40.

    Bull F, Milton K, Kahlmeier S. Health-Enhancing Physical Activity (HEPA) Policy Audit Tool (PAT) Version 2. Copenhagen, Denmark: WHO Regional Office for Europe; 2015. Accessed January 23, 2018.

    • Search Google Scholar
    • Export Citation
  • 41.

    Mozaffarian D, Angell SY, Lang T, Rivera JA. Role of government policy in nutrition—barriers to and opportunities for healthier eating. BMJ. 2018;361:k2426. PubMed ID: 29898890 doi:10.1136/bmj.k2426

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42.

    McHugh ML. Interrater reliability: the kappa statistic. Biochemia medica. 2012;22(3):276282. doi:10.11613/BM.2012.031

  • 43.

    Milton K, Bauman A. A critical analysis of the cycles of physical activity policy in England. Int J Behav Nutr Phys Act. 2015;12(1):8. doi:10.1186/s12966-015-0169-5

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44.

    Sacks G, Swinburn B, Lawrence M. Obesity policy action framework and analysis grids for a comprehensive policy approach to reducing obesity. Obes Rev. 2009;10(1):76–86. PubMed ID: 18761640 doi:10.1111/j.1467-789X.2008.00524.x

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45.

    de Nazelle A, Nieuwenhuijsen MJ, Antó JM, et al. Improving health through policies that promote active travel: a review of evidence to support integrated health impact assessment. Environ Int. 2011;37(4):766–777. PubMed ID: 21419493 doi:10.1016/j.envint.2011.02.003

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 46.

    Reis RS, Salvo D, Ogilvie D, Lambert EV, Goenka S, Brownson RC. Scaling up physical activity interventions worldwide: stepping up to larger and smarter approaches to get people moving. Lancet. 2016;388(10051):1337–1348. PubMed ID: 27475273 doi:10.1016/S0140-6736(16)30728-0

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47.

    Bull FC, Bellew B, Schöppe S, Bauman AE. Developments in National Physical Activity Policy: an international review and recommendations towards better practice. J Sci Med Sport. 2004;7(1 suppl 1):93–104. doi:10.1016/S1440-2440(04)80283-4

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48.

    Giles-Corti B, Whitzman C. Active living research: partnerships that count. Health & Place. 2012;18(1): 118–120. PubMed ID: 22243914 doi:10.1016/j.healthplace.2011.09.010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 49.

    Bellew B, Bauman A, Kite J, et al. Obesity prevention in children and young people: what policy actions are needed? Public Health Res Pract. 2019; 29(1);e2911902. doi:10.17061/phrp2911902

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 50.

    Brown DR, Soares J, Epping JM, et al. Stand-alone mass media campaigns to increase physical activity: a community guide updated review. Am J Prev Med. 2012;43(5):551–561. PubMed ID: 23079180 doi:10.1016/j.amepre.2012.07.035

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 51.

    Dunton GF, Cousineau M, Reynolds KD. The intersection of public policy and health behavior theory in the physical activity arena. J Phys Act Health. 2010;7(suppl 1):S91–S98. doi:10.1123/jpah.7.s1.s91

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52.

    Peeters A, Backholer K. How to influence the obesity landscape using health policies. Int J Obes. 2017;41:835–839. doi:10.1038/ijo.2017.24

  • 53.

    World Health Organization (WHO). ACTIVE: A Technical Package for Increasing Physical Activity. Geneva, Switzerland: WHO; 2018. https://apps.who.int/iris/handle/10665/275415. Accessed December 18, 2018.

    • Search Google Scholar
    • Export Citation
  • 54.

    Varney J, Brannan M, Aaltonen G. Everybody Active, Every Day: Framework for Physical Activity. London, UK: Public Health England; 2014. https://www.gov.uk/government/publications/everybody-active-every-day-a-framework-to-embed-physical-activity-into-daily-life. Accessed February 11, 2019.

    • Search Google Scholar
    • Export Citation
  • 55.

    Ministry of Social Affairs and Health, and Ministry of Education and Culture. On the Move National Strategy for Physical Activity Promoting Health and Wellbeing 2020. Finland, UK: Ministry of Social Affairs and Health; 2013. http://julkaisut.valtioneuvosto.fi/handle/10024/69943. Accessed February 11, 2019.

    • Search Google Scholar
    • Export Citation
  • 56.

    Bauman A, Bellew B, Vita P, Brown W, Owen N. Getting Australia Active: Towards Better Practice for the Promotion of Physical Activity. Melbourne, Australia: National Public Health Partnership; 2002.

    • Search Google Scholar
    • Export Citation
  • 57.

    Magnusson RS. What’s law got to do with it part 1: a framework for obesity prevention. Aust New Zealand Health Policy. 2008;5:10. PubMed ID: 18533998 doi:10.1186/1743-8462-5-10

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 58.

    Butland B, Jebb S, Kopelman P, et al. Foresight. Tackling Obesities: Future Choices—Project Report (2nd ed.). London, UK: Government Office for Science; 2007. www.gov.uk/government/uploads/system/uploads/attachment_data/file/287937/07-1184x-tackling-obesities-future-choices-report.pdf. Accessed May 15, 2019.

    • Search Google Scholar
    • Export Citation
  • 59.

    Keating CB, Katina PF. Complex system governance development: a first generation methodology. Int J Sys Eng. 2016;7(1–3):43–74. doi:10.1504/IJSSE.2016.076127

    • Search Google Scholar
    • Export Citation
  • 60.

    Fallding J. A Baseline of Healthy Eating and Active Living within NSW Local Government Community Strategic Plans and selected Delivery Programs. Sydney, Australia: New South Wales Premier’s Council for Active Living; 2016. https://www.nswpcalipr.com.au/assets/FINAL-A-Baseline-of-Healthy-Eating-and-Active-Living-Within-NSW-Local-Government-Community-Strategic-Plans-and-Selected-Delivery-Programs-v2.pdf. Accessed December 18, 2018.

    • Search Google Scholar
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

Nau, Lee, Smith, Bellew, Reece, and Bauman are with the Prevention Research Collaboration, Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia. Nau, Lee, Smith, Bellew, and Bauman are with The Australian Prevention Partnership Centre, Sydney, NSW, Australia. Gelius is with the Department of Sport Science and Sport, University of Erlangen-Nuremberg, Erlangen, Germany. Rutter is with the Department of Social and Policy Sciences, University of Bath, Bath, United Kingdom.

Nau (tracy.nau@sydney.edu.au) is corresponding author.