Harmonized Report Card Development

Report Card teams from 57 countries followed harmonized procedures to develop their Report Cards by grading 10 common PA indicators (Overall Physical Activity, Organized Sport and Physical Activity, Active Play, Active Transportation, Sedentary Behavior, Physical Fitness, School, Family and Peers, Community and Environment, and Government) using the best available data and evidence. Details outlining the methodology have been described previously.²²

In brief, the AHKGA encouraged Report Card teams registered in the Global Matrix 4.0 to engage (and expand if necessary) a multidisciplinary team of PA experts representing a variety of sectors (eg, research, health, sport, education, communities, policy) and to identify an official Leader/Co-Leaders who would be in charge of (1) stewarding the development of their Report Card and (2) maintaining communication between the AHKGA and their Report Card team. Report Card teams gathered available data and supporting information (and performed additional analyses or collected data in some cases) that best aligned with the 10 common PA indicator benchmarks for children and adolescents aged 5–17 years. The definitions and associated benchmarks for each of the PA indicators are presented in Table 1. Subsequently, and based on the findings of literature reviews and data analyses, each indicator was assigned a grade by each country using the harmonized grading rubric shown in Table 2. When insufficient data/evidence were available to grade the indicators, an incomplete grade, “INC,” was assigned.

All Report Card teams completed and submitted a standardized spreadsheet template summarizing their tentative grades for each of the 10 indicators, with rationales and references supporting the proposed grades. This information was audited by at least 2 AHKGA researchers who approved the grades or provided feedback that required attention to improve the alignment of the grades and their associated rationales with the benchmarks and grading rubric, potentially leading to a change of grade. Consecutive rounds of audits were performed until a final version of the grade and rationale spreadsheet was approved by all auditors. A total of 121/570 grades were changed as a function of the process (ie, first draft grades submitted to the AHKGA for audit vs final approved grades included in the Global Matrix 4.0). The revisions to the grades were made by 42/57 participating countries mostly in response to the feedback received from the AHKGA auditing team, while a few grade changes occurred for different reasons (eg, noticed typo mistake, got access to new/additional data). Grade adjustments ranged from small (eg, C to C+, A− to B+) to more substantial (eg, D to A−, B− to F), including revisions from INC to a letter grade or vice versa. Sedentary Behavior was the indicator with the most grade revisions (n = 17), whereas changes to the Organized Sport and Physical Activity indicator grades were the least frequent (n = 8). The Report Card teams could also provide grades for additional indicators of their choice in their Report Card, but these were not audited due to a lack of standardized Global Matrix benchmarks for such indicators.

An online survey was created using Google Forms (Google LLC) and distributed in April 2022 to all Report Card team Leaders and Co-Leaders. As the grades could be informed by evidence dating from before the COVID-19 pandemic was officially declared (March 11, 2020),²⁵ after, or by evidence from both periods, this survey was created (1) to collect Report Card Leaders’ top 3 priority actions for each PA indicator; (2) to assess which national grades were informed by pre-COVID-19 pandemic evidence and/or current pandemic evidence; and (3) to obtain Report Card Leaders’ opinion on how the pandemic might have affected PA indicators, PA research, and PA surveillance. Additional questions were included to assess whether based on the Report Card Leaders’ expert opinion and available information, they considered that the PA of children and adolescents in their country was currently affected by local or international wars/conflicts, local climate change/climate change mitigations, and/or local economic changes/challenges.

Statistical Analysis

The 57 participating countries were divided into 3 HDI²⁶ classifications (low and medium, high, and very high) and 5 geo-cultural regions (Africa and the Middle East, Anglosphere,²⁷ Asia-Pacific, Europe, and Latin America) to facilitate data synthesis. The Anglosphere corresponds to the group of countries of the world in which the English language and cultural values predominate.^27,28 As Northern Africa and the Middle East are often grouped together by major organizations, such as the United Nations, and considering the limited number of participating countries from Africa and the Middle East, these 2 regions were grouped together by convenience for the analyses presented in this paper. The HDI value, HDI classification, and geo-cultural region for each participating country are presented in Table 3. The HDI classifications were extracted from the 2020 Human Development Report.²⁹Average grades were calculated by country, PA indicator, HDI classification, and geo-cultural region using the letter grade corresponding to percentages presented in Table 2, and INC were treated as missing values (missing values were deleted).

Each PA indicator was compared across countries exploring differences related to geo-cultural regions and HDI classification. Three aggregate indicators were generated for the analysis: (1) behavioral indicator (average grade for the indicators of Overall Physical Activity, Organized Sport and Physical Activity, Active Play, Active Transportation, and Sedentary Behavior); (2) sources-of-influence indicator (average grade for Family and Peers, School, Community and Environment, and Government); and (3) overall average indicator (average grade of the 10 common indicators). Summary tables presenting averages and grade counts that were informed by pre-COVID-19, post-COVID-19, or both were created to support comparison. Linear and generalized regression (Poisson) models were fitted and evaluated to quantify the associations between geo-cultural regions and HDI classification (covariates in the model) and the prediction of the number of A, B, and C grades or the prediction of INC grades (dependent variables) utilizing all individual grades from the participating countries (n = 57). Poisson models were used to fit models where the outcome variables were not normally distributed and exhibited a zero-inflated distributed (strong positive skew). When models were fit, missing values were deleted given that these models apply listwise deletion to missing data. All analyses were performed using RStudio (version 2202.07.1) Build 554, and alpha level was set at .05.

Participating Countries

Sociodemographic and geographic characteristics showed 74% of the participating countries were classified as having very high HDI, 19% were high HDI, and 7% were low or medium HDI. Geographically, 37% of the participating countries were located in Europe, followed by 23% located in Asia-Pacific, 17% Anglosphere, 12% in Africa and the Middle East, and 11% in Latin America.

Global Matrix 4.0 Physical Activity Grades

The grades for the 10 common PA indicators and the 3 aggregate indicators (ie, behavioral indicator, sources-of-influence indicator, and overall average indicator) are presented by participating country in Table 4. A total of 570 grades, including 465 (82%) letter grades and 105 (18%) “INC” grades, were assigned by the 57 Report Card teams. Countries with the highest behavioral indicator grades were Finland and Japan (B−); with the highest sources-of-influence indicator grades were Malaysia and Sweden (B+); and with the highest overall average indicator grade were Denmark, Finland, Japan, and Slovenia (B−). Countries with the lowest behavioral indicator, source-of-influence indicator, and overall average indicator grades were the United Arabic Emirates (UAE) (F); Botswana, China, Indonesia, and Lebanon (D); and Indonesia (D−), respectively.

In addition to the 10 common PA indicators, a total of 22 countries graded additional indicators that were not part of the harmonized Global Matrix 4.0 development process. Additional indicators included Sleep (number of countries with the indicator: n = 14), Body Mass Index/Weight Status (n = 12), Physical Literacy (n = 5), Diet (n = 2), and 9 other additional indicators each graded by a single country (Mental Health, Anxiety & Stress, Bullying, Student Engagement, Physical Education, Adherence to 24-hour Movement Guidelines, Yoga, Psychosocial Factors, and Seasonal Variation).

The average grades by HDI classification are presented for each indicator and grouped indicators in Table 5. For all countries (n = 57), the indicators with the highest average grade were School and Community and Environment (C+), while the indicator with the lowest average grade was Overall Physical Activity (D). For very high HDI countries (n = 42), the indicators with the highest average grade were School and Community and Environment (B−), whereas the indicator with the lowest average grade was Overall Physical Activity (D+). For high HDI countries (n = 11), the indicators with the highest average grade were Active Transportation, Family and Peers, School, and Government (C−). In contrast, the indicator with the lowest average grade was Active Play (D−). For low and medium HDI countries (n = 4), the indicators with the highest average grade were Active Play, Active Transportation, and School (C+); the indicators with the lowest average grade were Overall Physical Activity, Community and Environment, and Government (D–). The average grades for the grouped indicators were almost the same when comparing all countries to the very high HDI countries (D+ for behavioral indicator, C− for overall average) with only a small difference for the sources-of-influence indicator (C for all countries, C+ for very high HDI countries). The average grades for the behavioral indicator, the source-of-influence indicator, and the overall average for high HDI countries were D, C−, and D+, respectively, whereas all the grouped indicator average grades were C− for the low and medium HDI countries.

The average grades by geo-cultural area are presented for each indicator and grouped indicator in Table 6. Countries from Africa and the Middle East (n = 7) had the highest average grades for Active Play (C+), Sedentary Behavior (C−), and Physical Fitness (C+); and the lowest average grades were for Family and Peers (D−), Community and Environment (D+), Government (C−), and the sources-of-influence indicator (D+). Countries from Europe (n = 21) had the highest average grades for School (B), behavioral indicator (C−), and for the overall average indicator (C). For Overall Physical Activity, countries from the Anglosphere (n = 10) and Europe (n = 21) shared the highest average grade (D+), and countries from the Asia-Pacific had the lowest average grade (D−). For Organized Sport and Physical Activity, countries from the Anglosphere and Europe shared the highest average grades (C), while countries from Africa and the Middle East (n = 7), Asia-Pacific (n = 13), and Latin America (n = 6) shared the lowest average grade (D+). For Active Transportation, countries from the Asia-Pacific, Europe, and Latin America shared the highest average grade (C), while countries from the Anglosphere had the lowest average grade (D+). For School, countries from Africa and the Middle East and from Latin America shared the lowest average grade (C). For the behavioral indicator, countries from the Anglosphere and Latin America shared the lowest average grade (D), while for the sources-of-influence indicator, countries from Asia-Pacific and Europe shared the highest average indicator grade (C+).

Impact of the COVID-19 Pandemic

The indicator grade counts and averages (excluding the INC grades) by data collection/evidence period (before the COVID-19 pandemic was officially declared, after, or both) are presented in Table 7. In total, 411 letter grades were informed by evidence pre-COVID-19 pandemic, 47 grades were informed by evidence after the start of the COVID-19 pandemic, and 141 grades were informed by evidence from both periods (several countries took the initiative to grade the same indicator for more than one period). The overall average grade for each period is D+.

A total of 84 Report Card Leaders/Co-Leaders from 53 countries across 6 continents replied to the online survey. Their perceptions of the impact that the COVID-19 pandemic had on each of the 10 common PA indicators, on the surveillance of PA in children and adolescents, and on their activity as PA experts/researchers are summarized in Table 8. Most Report Card Leaders reported that the COVID-19 pandemic adversely affected the 10 common PA indicators in their country. In terms of PA surveillance and their activity as PA experts, the results were more disparate. One in 2 Report Card Leaders reported that their activity as a PA researcher/expert was negatively affected by the COVID-19 pandemic, while 57% reported a negative impact of the pandemic on surveillance of PA among children and adolescents. A positive impact on their research/expert activity was reported by 23% of the Report Card leaders, while 14% of the Report Card Leaders reported a positive impact on surveillance of PA among children and adolescents.

Priorities to Improve the Global Matrix Grades

In the online survey, Report Card Leaders (n = 83) also provided the top 3 priorities they identified to improve each of the 10 common PA Global Matrix 4.0 indicators. A summary of the most frequent priority themes is provided for each indicator in Table 9.

Impact of War, Climate Change, and Economic Change

In the online survey, 13 Report Card Leaders from 8 countries (Colombia, Ethiopia, India, Israel, Lebanon, Lithuania, Poland, and South Africa) reported that the PA of children and adolescents is potentially currently negatively affected by local or international war/conflicts. A total of 25 Report Card Leaders from 17 countries (Basque Country, Botswana, Brazil, Colombia, Ethiopia, India, Japan, Lebanon, Malaysia, Philippines, Poland, Slovakia, Slovenia, South Africa, South Korea, Thailand, and Zimbabwe) reported that the PA of children and adolescents is currently negatively affected by local climate change/climate change mitigations. Finally, more than half of the Report Card Leaders (n = 43) from 28 countries (Basque Country, Botswana, Brazil, Canada, Chile, Chinese Taipei, Colombia, Czech Republic, England, Estonia, Ethiopia, Hong Kong, India, Indonesia, Ireland, Israel, Lebanon, Nepal, Region of Murcia, Scotland, Slovakia, Slovenia, South Africa, South Korea, Spain, Uruguay, Wales, and Zimbabwe) reported that based on their expert opinion and available information, the PA of children and adolescents in their country or territory is currently negatively affected by local economic changes/challenges.

Multivariable Analyses of Factors Associated With the Global Matrix Grades

Results from the linear model assessing the associations between HDI classification, geo-cultural regions, and the number of A, B and C grades are presented in Table 10. Compared with countries from Africa and the Middle East, European countries had about 2 more A, B, or C grades on average after controlling for HDI (β = 2.04; 95% confidence interval, 0.06 to 4.03; P = .004). A Poisson model examining the associations among HDI classification, geo-cultural regions, and the number INC grades is presented in Table 11. Similar to the linear model findings, results of the Poisson model show that in comparison with countries from Africa and the Middle East, European countries were less likely to have INC grades after controlling for HDI (Incidence rate ratios [IRR] = 0.44; 95% confidence interval,  0.22 to 0.95; P = .030).

Overall Physical Activity (D)

The Overall Physical Activity benchmark was modified in 2018 to better align with the new Canadian guidelines for PA,³³ becoming the percentage of children and adolescents who accumulate at least 60 minutes of MVPA per day on average across the week. In 2020, the WHO also released updated PA guidelines for the same age group,¹ adopting the same threshold for MVPA (ie, 60 min/d on average). While this change is a step forward supported by scientific evidence^34,35 for the global health promotion of children and adolescents, it resulted in major challenges for the surveillance of PA,³⁶ and the interpretation of findings and trend analyses, challenging the Report Card teams assessing this indicator. Most PA questionnaires/surveys were not designed to evaluate this new threshold. To address this challenge, the AHKGA proposed an additional alternative benchmark: “% of children and adolescents meeting the guidelines on at least 4 days a week (when an average cannot be estimated)” to help Report Card teams using the available evidence to grade this indicator. This alternative benchmark was based on analysis of accelerometry data from the Canadian Health Measures Survey,³⁷ showing that children who met the MVPA threshold of 60 minutes per day on average corresponded to the children meeting at least 60 minutes of MVPA per day, 4 days per week.³⁷ Recent work from Gammon et al³⁵ used the International Children’s Accelerometry Database to compare PA thresholds compliance and their associations with health indicators and found that children completing 60 minutes of MVPA every day do not experience superior health benefits compared with adolescents completing an average of 60 minutes of MVPA per day.

Three countries assigned an INC to the Overall Physical Activity indicator (ie, Poland, Scotland, and Basque Country). Hong Kong and Sweden were the only countries that graded the indicator based solely on accelerometry data, and 10 countries had their grades informed by both device-measured and self/proxy-reported data (ie, Czech Republic, Denmark, Finland, Germany, Guernsey, Estonia, India, Ireland, Portugal, UAE, and Zimbabwe), the grades for the remaining countries were informed by self/proxy-reported data. Among the 54 Report Card teams that assigned a grade to this indicator, 14 used the previous WHO PA guideline threshold (ie, at least 60 min of MVPA daily), 9 used the new WHO guidelines’ threshold (ie, 60 min of MVPA per day on average), and 9 used the alternative benchmark proposed by AHKGA (ie, at least 60 min of MVPA per day, 4 d/wk) to inform their grades. The remaining countries used a combination of these 3 thresholds, and in a few cases, other threshold variations determined by the best available data in their country/territory (eg, at least 60 min of MVPA per day, 5 d/wk; 9000 steps/d; “high PA level,” achieve “20-30 min of exercise and running four days or more per week”). These findings align with the top priorities reported by the Report Card Leaders calling for the development or improvement of current PA surveillance systems (Table 9) and are consistent with recent work⁷ that highlighted inconsistencies across and within PA surveillance initiatives globally calling for the development of a new valid and reliable PA measurement instrument that would be globally accepted and harmonized. Regarding the age groups covered by the evidence informing the Overall Physical Activity grades, the grades for 33 countries were informed by evidence including both adolescents and children aged below 10 years, while the grades for 20 countries were informed by evidence only including adolescents, and the grade for one country (Montenegro) was informed by evidence only including children below 10 years. Having more than half of the countries reporting evidence including children below 10 years is an encouraging outcome, as this age group is generally underrepresented compared with adolescents (11–17 y olds) across international PA surveillance initiatives.⁷

Grades for the Overall Physical Activity indicator ranged from F (Chinese Taipei, Ethiopia, Extremadura, Hungary, Indonesia, Jersey, Philippines, UAE, Uruguay, Viet Nam, and Wales) to A− (Slovenia and Finland). Similar to the Global Matrix 3.0 in 2018,²² Overall Physical Activity was the indicator with the lowest average grade (D), which corresponds to an estimation of only 27% to 33% of children and adolescents meeting the recommended amount of MVPA. Moreover, the average grade remained within D− and D+ when stratified by HDI classification or geo-cultural region. In total, only 15 (28%) countries out of the 54 that graded this indicator had a grade of C (ie, “we are succeeding with about half of children and adolescents (47%–53%)”) or higher. Collectively, these findings, consistent with previous work,^7,9 suggest that overall the situation regarding the PA of children and adolescents globally is alarming, with only a small proportion meeting the recommended amount of MVPA (27%–33%), and major actions (see Table 9 for priorities identified by Report Card Leaders) are needed to increase PA opportunities for all children and adolescents globally. A major and rapid shift is needed to reach the target of reducing physical inactivity by 15% by 2030 established by the WHO in their Global Action Plan for Physical Activity (GAPPA).³²

Organized Sport and Physical Activity (C−)

The benchmark for Organized Sport and Physical Activity remained unchanged since the Global Matrix 3.0. As previously mentioned,²² this indicator did not provide any information on the dose (ie, duration, frequency, intensity) of sport participation, so the grade for this indicator depends on the availability of organized sport opportunities and of the availability of data/national reports presenting the prevalence of children and adolescents who have taken advantage of these opportunities.

Eight countries almost exclusively from Asia and Middle East (ie, India, Jersey, Lebanon, Malaysia, Philippines, South Korea, UAE, and Viet Nam) assigned this indicator an INC grade. Grades for Organized Sport and Physical Activity were informed in most countries by self- or proxy-reported surveys (n = 37), and 6 countries (Botswana, France, Slovenia, Extremadura, Chinese Taipei, and Uruguay) graded this indicator based on national statistics/reports from sport ministries, federations, or associations. Five countries (Croatia, Greenland, Israel, Serbia, and Estonia) graded this indicator based on both (ie, survey and national statistics), and one country graded this indicator based on a systematic review of 5 studies (Brazil). These findings highlight that there is room for improvement for the surveillance of this indicator. As the majority of its evaluation comes from surveys, it would be worth investing in the development of questionnaire items more precisely assessing the dose of Organized Sport and Physical Activity to identify how much PA the sport participation provides, as well as qualitative information such as the specific sport(s) practiced to determine its/their associated specific physiological demands, social characteristics, potential benefits, and activity category from the Youth Compendium of Physical Activities.⁴⁴ Additionally, the small number of countries that graded this indicator using national statistics/reports suggest that national data of children and adolescents engaged in sport clubs were either nonexistent, not available, or of low quality in the majority of countries. This is a missed opportunity for collecting useful data that could inform the surveillance of the dose of this indicator and assist in planning the evaluation of sport policies and guide promotional efforts.

Organized Sport and Physical Activity grades ranged from F (China, Indonesia, and Uruguay) to A (Denmark). On average, this indicator was graded C−, corresponding to succeeding with about 40% to 46% of children and adolescents. Notably, inequities were visible for this indicator as the average was C for countries from the Anglosphere and Europe, and D+ for the countries from Africa and the Middle East, Asia-Pacific, and Latin America. These findings are consistent with previous work that highlighted significant low to moderate positive associations between Organized Sport and Physical Activity and several sociodemographic indicators and significant low negative associations between this indicator and inequality indices (eg, Gini index and Gender Inequality Index).²² Physical and mental health benefits from participation in sport for children and adolescents are documented in the literature,⁴⁵ and sport participation may provide additional benefits such as improved motor skills and multiple fitness components (ie, muscular strength, endurance, flexibility, cardiorespiratory fitness).⁴⁶ Time, cost, and location have been repeatedly identified as key practical barriers to children’s participation in sports, as well as peer disapproval and gender stereotyping.⁴⁵ In high-income countries, socioeconomic disparities in sport participation were recently found to be greater than in overall PA participation among children and adolescents, highlighting the importance of targeting sport programs according to socioeconomic gradients,⁴⁷ as suggested by Report Card Leaders (Table 9). Broadening the definition and approach of organized sports, including lifelong and action sports, outdoor sports, and to use sport as an agent of inclusion, development of skills, enjoyment, and not only for competition, was identified as an international priority (Table 9). The authors recommend applying the guiding principles from the Sports Club for Health approaches^30,48 whose development was supported by health-enhancing PA (HEPA) European network. More research is needed to identify barriers and enablers in low- and middle-income countries, and to examine if accessible and attractive sport opportunities are offered to all children and adolescents locally, nationally, and globally.

Active Play (C−)

Active play is a “form of play that involves PA of any intensity”⁵⁰ and is often related to outdoor activities. Play is identified as an essential component of child development and helps with the refinement of physical abilities and fosters social development, self-concept, and creativity.⁵¹ More research is needed to improve the understanding of what active play is and its importance. As there is no globally approved methodology to measure Active Play, or benchmarks to assess it against, the benchmark used for this indicator was adopted from the Canadian Report Card.⁵²

Active Play is the behavioral indicator with the most INC grades as 27 countries were not able to assign a grade. The data informing the letter grades vary greatly across the 30 countries that graded this indicator: 11 had their grade informed by data that did not correspond to a duration threshold (eg, “engage in leisure-time physical activities;” “go outside to play or be active in their free time on most of the days of the week;” “regularly engage in active play;” “report playing out a few days each week”), and 19 used various duration thresholds fitting appropriately with the Global Matrix benchmarks (eg, “engaged in unorganized PA and/or active play for at least two hours of their free time a day;” “involved in outdoor active play at different intensity for more than 2 hour per day”) with the exception of one country (Montenegro) whose best available data on Active Play was using “unstructured/unorganized active play at least one hour per day.” Active play, in contrast with sport, physical education and active transportation, can often be accumulated in a sporadic way, rather than during organized/specific time periods—ultimately making it challenging to assess and potentially limiting the utility of time-based thresholds. These findings highlight the urgent need for the development of a valid and reliable instrument to measure Active Play that would be acceptable and adaptable globally and across all geo-cultural contexts while remaining true to the core meaning and importance of active play.

The Active Play grades ranged from F (Thailand, Brazil, Indonesia, and Chinese Taipei) to B+ (Region of Murcia), followed closely by Montenegro, Serbia, and Ethiopia (with a B). On average, this indicator was graded C−, corresponding to 40% to 46% of children and adolescents meeting the criteria, but this average varied when stratified by HDI classification, ranging from D− (high HDI countries) to C+ (low and medium HDI countries), and when stratified by geo-cultural regions, ranging from D− (Asia-Pacific) to C+ (Africa and the Middle East). While these variations should be considered cautiously, such findings suggest that there are inequities in terms of barriers and opportunities for active play in children and adolescents across the world. The Childhood Obesity Surveillance Initiative study also observed gender differences and significant variations between countries in children’s active play and pointed out that these differences might be explained by different cultural values toward active play and sedentary behavior, related to different climate, and affected by the length of the day.⁵³ In Asia, the most frequently mentioned barrier to children’s and adolescents’ PA was “the lack of time because of schoolwork,”⁵⁴ and this specific barrier would also affect active play. In Thailand, active play is also sensitive to gender and culture: Adolescent girls are disadvantaged by the Thai cultural norm dictating that girls are supposed to be neat and calm and are discouraged from engaging in vigorous outdoor activities that may produce sweat and disheveled appearance.⁵⁵ Top priorities such as increasing and improving play facilities in the public environment, raising awareness about the importance of active play, and increasing active play opportunities in the school setting were identified by Report Card Leaders globally (Table 9).

Active Transportation (C−)

Active transportation involves nonmotorized travel modes such as walking, cycling, or riding a human-powered scooter.⁵⁸ The benefits of active transportation include not only increases in PA at the individual level⁵⁹ but also improvements in traffic safety, transportation mode share, air pollution, and reductions in carbon emissions on a larger scale, potentially contributing to multiple United Nation Sustainable Development Goals.⁶⁰ The benchmark for the Active Transportation indicator (Table 1) does not specify a required volume to assign a grade.

Only 3 countries (Argentina, Greenland, and Extremadura) were unable to grade this indicator due to a lack of relevant data. All Active Transportation grades were informed by self/proxy-reported data mostly focusing on transportation modes to and from school, yet substantial variations were observed between these grades. A variety of specific frequency thresholds for this indicator (eg, “used active transportation during weekdays at least two times a week;” “using active transport at least once per week;” “use active transportation any of the previous 7 days”) was used by surveys assessing this indicator, as well as using active transportation as the “usual” or “single” mode of transport to and from school. These findings suggest that the global surveillance of active transportation also needs the development of a more standardized measurement tool, widely validated, and geographically (considering the topographic variations that may affect the mode of active transportation within a country)⁶¹ and culturally appropriate or adaptable to all settings and across all age ranges of children and adolescents.

Grades for this indicator ranged from F (UAE) to A− (Denmark and Japan). On average, this indicator was graded C−, corresponding to succeeding with about 40% to 46% of children and adolescents. Minimal variation was observed across HDI classifications (Table 5) and between geo-cultural regions (Table 6). In countries with high-income inequalities and with a lower HDI, a high prevalence of active transportation could potentially reflect a necessity induced by a lack of alternative motorized options rather than a choice,⁶² is not necessarily associated with a safe environment for walking/cycling and is potentially threatened by economic transition. In contrast, a high prevalence of active transportation in very high HDI countries with low-income inequalities is likely to be the result of successful policies promoting active transportation, and of local cultural norms and infrastructure. Concrete actions to improve active transportation globally were identified by the Report Card Leaders (Table 9).

Sedentary Behaviors (D+)

Sedentary behaviors are defined as “any waking behavior characterized by an energy expenditure ≤1.5 metabolic equivalents while in a sitting, reclining, or lying posture.”⁶⁶ The rapid evolution of technologies and ubiquity of digital media over the past century have fundamentally affected the way children and adolescents recreate, learn at school, and commute. It is hypothesized that an increased exposure to artificial light, clocks, and multiple screen-based devices (eg, smart phones, tablets, TV, computers) in their daily life as well as the use of motorized forms of transportation led to a new norm wherein children and adolescents have become increasingly sedentary during their leisure and transportation time.^67,68 However, global assessment of sedentary behavior trends in children and adolescents is lacking. Sedentary behavior is complex, encompassing a variety of behaviors (eg, watching TV, playing videogames, using a computer, reading a book, sitting while eating or in a car, or at school or work) that have an intricate relationship with health and generates debates across experts in the field. Systematic reviews suggests that for children and adolescents, greater time spent in sedentary behavior, in particular recreational screen time, is associated with poorer health outcomes such as lower fitness, poorer cardiometabolic health, shorter sleep duration, unfavorable measures of adiposity, and poorer mental health, while some specific sedentary behaviors, such as reading and completing homework outside of school, are favorably associated with academic achievement.^34,69–71 In contrast, other research groups contest these interpretations of the current evidence and assert that sedentary time assessed with accelerometers is largely uncorrelated with markers of adiposity, and while there is some evidence on the association between screen time and adiposity, it is not sufficient to make inferences about causality.⁷² Overall, the study of sedentary behaviors is still in its early stage unlike PA research and is challenged by its constant evolution (ie, technological changes are still rapidly occurring, leading to new screen-based devices and transportation modes that are regularly introduced into children and adolescents’ life) and by the lack of standardized assessment methodology capturing its complexity that would allow more accurate and reliable global surveillance.

In this context, the WHO recently recommended that “children and adolescents should limit the amount of time spent being sedentary, particularly the amount of recreational screen time”¹ while considering that there is currently insufficient evidence to specify precise cutoffs for recreational screen time.³⁴ In contrast, the 2016 Canadian 24-Hour Movement Guidelines for Children and Youth stated that based on the available evidence, children and adolescents should not engage in more than 2 hours per day of recreational screen time and limit sitting for extended periods.³³ The benchmark used for this indicator (Table 1) was adopted based on the Canadian guidelines.³³

Only 2 countries (Finland and Greenland) were unable to grade the Sedentary Behaviors indicator. Grades for 28 countries were informed by survey data using a screen time threshold fitting with the benchmark, and grades for 12 countries were informed by survey data using a slightly different threshold (ie, less than 2 h of recreational screen time). Grades for 4 countries were informed by data using a threshold of “less than two hours a day” of various screen-based behaviors such as watching TV, using a computer, or playing video games that were accumulating but could not access to the raw data to calculate the prevalence of having these behaviors not cumulating more than 2 hours per day. Four countries graded this indicator based on self-reported sitting data using “less than three hours per day on sitting activities on a typical day.” One country (UAE) graded this indicator based on accelerometer-derived estimates of daily sedentary time using a “less than two hours” threshold. The 7 remaining countries used unique screen time or sedentary time thresholds or a combination of both to inform their grades. The observed variation of data across countries for this indicator is a direct result of the aforementioned lack of consensus in terms of the link between sedentary behavior and health and of how to assess this indicator in children and adolescents, suggesting that extensive work is needed to address both issues.

Grades for the Sedentary Behaviors indicator ranged from F (Wales, Canada, Scotland, and Thailand) to B (Philippines, Indonesia, and Montenegro). Overall, the average grade was D+ (ie, only succeeding with 34%–39%), suggesting that most children and adolescents across the world engage in recreational screen time above the recommendation. When stratified by HDI classification, the average grade is better when the HDI category is lower. These findings suggest that children and adolescents from countries of lower socioeconomic standard are potentially more protected from adverse outcomes associated with excessive screen time—but these better grades are potentially threatened by the economic transition these countries are experiencing—or that available survey data do not detect time spent on new screen devices such as smartphones. However, these results could also illustrate a general lack of access to screen devices for this specific population that would affect the possibility to acquire digital literacy, an essential skill to function in the modern world.

Physical Fitness (C−)

Physical fitness is a good summative measure of the body’s ability to perform PA and exercise, and it also provides an important summative indicator of health.⁷⁹ To evaluate this indicator, the AHKGA developed a standardized methodology using the average percentile achieved on certain physical fitness tests based on the European normative values published by Tomkinson et al²³ (as global normative values are still lacking). As conducting standardized physical fitness tests is more burdensome than distributing self/proxy-reported surveys, more than half (n = 31) of the countries could not assign it a grade due to lack of data, making Physical Fitness the indicator with the most INC grades. Among the 26 countries that were able to grade this indicator, grades were informed by a combination of 20-m shuttle run test and other standardized fitness tests (n = 12), solely by the 20-m shuttle run test data (n = 8), and by various standardized fitness tests not including the 20-m shuttle run test (n = 6). These data characteristics vary greatly in terms of sample size, sample age, collection time, and availability of raw data, potentially affecting their grading and interpretation. The availability of 20-m shuttle run test data in 20 countries participating in the Global Matrix 4.0 is also an encouraging finding as it is an appropriate field-based measure of cardiorespiratory fitness with moderate to high criterion-related validity and high reliability, and cardiorespiratory fitness is an important indicator of current and future health among school-aged children and adolescents.⁸⁰

Grades for the Physical Fitness indicator ranged from F (Indonesia) to A (Slovenia). Countries that assigned a grade were very high HDI countries (n = 23) and high HDI countries (n = 4, Botswana, Brazil, Indonesia, and South Africa). Similarly, only 5 countries from the Asia-Pacific region, 3 countries from the Anglosphere, 2 countries from Africa and the Middle East, and 1 country from Latin America were able to grade this indicator, which was mostly graded in European countries (n = 15). The high number of INC grades for this indicator highlights the need for further development of the global surveillance of physical fitness, requiring a simple and cost-effective assessment⁸¹ that could be integrated into physical education classes and/or recreation/sport programs. Consequently, the C− (ie, about 40%–46% are estimated to reach an adequate physical fitness level) observed as the average grade for Physical Fitness cannot be considered a generalizable global estimation, yet still emphasizes the need for the implementation of programs to improve fitness levels in children and adolescents internationally alongside surveillance.

Family and Peers (C−)

Evidence from the literature shows that family members’ and peers’ influence are important correlates of the PA of children and adolescents.^45,84–89 The relationship between family members/peers and children’s and adolescents’ PA is complex and needs more research to be understood in various geo-cultural settings, yet the AHKGA considered the following processes through which parent/peers may have a positive influence on PA to establish the benchmarks for this indicator (Table 1): support for PA, role modeling, and co-participation.⁹⁰

A total of 13 countries were unable to grade the indicator because of lack of available data. Due to a lack of valid and internationally recognized instrument for assessing the influence of family and peers on PA of children and adolescent, and due to numerous benchmarks available for this indicator, the rationales and data informing this indicator’s grades varied greatly across countries. Overall, the grades were informed by self/proxy-reported data with various sample size, sample age, and collection time on a variety of aspects of family and peers’ influence on PA: parents meeting adult PA guidelines,¹ parents facilitating PA and sport opportunities for their children and/or placing limits on screen time, and children or adolescents participating in PA or sports with peers or an adult family member.

Grades for this indicator ranged from F (Indonesia and Ethiopia) to A+ (Nepal), followed closely by Montenegro and Extremadura (with an A). The average grade for this indicator was C−, meaning that around 40% to 46% of children and adolescents were positively influenced by their peers/family members to be active. Almost no variation of this average was observed when stratified by HDI classification (Table 5), but more substantial differences were observed when stratified by geo-cultural regions (Table 6), suggesting a cultural influence on the familial and peer support of children’s and adolescents’ PA. This finding is commensurate with a qualitative study involving 6 single-ethnic focus groups of parents in England that showed additional barriers to children’s and adolescents’ PA for ethnic groups from cultures that prioritized educational attainment over PA (eg, Asian Bangladeshi, Chinese, Yemeni) and of Muslim faith (Asian Bangladeshi, Black Somali, Yemeni), who reported a lack of culturally appropriate opportunities for girls.⁹¹ Another study In Israel showed that Jewish adolescents reported higher levels of PA than Arab adolescents, and family and peers-related factors (parent, sibling, and peers’ engagement in PA, in-school PA breaks, and liking PA) were found positively associated with levels of PA, suggesting a potential cultural influence on the relationship between children’s and adolescents’ PA and the Family and Peers indicator.⁹²

School (C+)

School represents both a learning environment where children and adolescents spend a substantial proportion of their awake time and the place where they can attend physical education class. Depending on school PA policies and the existence of a national physical education curriculum, school has the potential to provide PA opportunities through physical education, lunch and recess breaks, in-class physical activities, competitive or noncompetitive activities before and after school, active transportation promotion initiatives, as well as educational activities and role modeling for an active lifestyle that may increase awareness and health literacy.^95,96 A series of benchmarks were established by the AHKGA to assess the existence of these opportunities (Table 1).

Five countries could not grade this indicator due to insufficient data. School grades were informed by an extensive variety of information including surveys targeting children and/or adolescents, parents, or schools assessing specific aspects of school PA policies, attendance of physical education, participation in school sport clubs, as well as national reports and descriptions of some national physical education curricula. Deeper analysis of these materials is needed to provide a more accurate overview of the information compiled to inform the School indicator at the global level. This is also the result of the complexity of concepts covered by the current School indicator. While physical education represents a PA domain,⁹⁷ it was included in the School indicator as part of the source of influence instead of as a separated behavioral indicator. While this approach is potentially more relevant for countries where the teaching of physical education is only scarce and dependent of school or municipal initiatives, having a separated behavioral indicator could be more appropriate for countries with a compulsory national physical education curriculum and would allow the Global Matrix to assess separately Overall Physical Activity and its four components (ie, organized sport, active play, active transportation, and physical education).⁹⁷

School grades ranged from F (Indonesia) to A+ (Hungary), followed closely by Portugal, Slovenia, Viet Nam, South Korea (A). School is one of the 2 indicators with the highest average grade, C+, suggesting that 54% to 59% of schools are PA supportive. When stratified by HDI classification, the average grade for School was higher in very high HDI countries (B−) than in low and medium HDI countries (C+) and even lower in high HDI countries (C−; Table 5). When stratified by geo-cultural region, the average grade for countries from Europe (B) was above the average grades for countries from other regions.

Community and Environment (C+)

Characteristics of the environment are recognized as important determinants of the PA of children and adolescents. For example, better accessibility to existing and new infrastructure for walking, cycling, and public transportation, as well as population density, public transportation density, the connectivity of streets, access and availability of public open spaces, and sports facilities are associated with increased overall and transportation-related PA^99–101; however, relevant environmental correlates of PA may be behavior and context specific.¹⁰² As a valid methodology to evaluate the environmental attributes affecting children’s and adolescents’ PA adaptable to all contexts is lacking, the AHKGA established a series of benchmarks to capture them, and the community/municipal initiatives implemented to improve them (Table 1).

A total of 9 countries could not grade the Community and Environment indicator due to a lack of sufficient data. The grades were informed by self/proxy-reported survey data in 26 countries, by national reports/data in 6 countries, by a combination of both in 14 countries, and by anecdotal observations reported in newspapers (Botswana) and expert opinion (Indonesia) in 2 other countries. The topics evaluated in these surveys/national data varied greatly across countries, including measures of perceived safety, walkability, access to park/playground/bike paths, and community initiatives. Deeper analysis focusing on this indicator is needed for providing a detailed overview of the characteristics of the Community and Environment indicator by HDI classification and by geo-cultural region.

Grades for the Community and Environment indicator ranged from D− (Botswana and China) to A+ (Slovenia, Sweden, and Singapore) with an average grade of C+. Inequities are observable for this indicator as there was a distinct gap between the average grade for the very high HDI countries (B−) and the average grade for the low, medium, and high HDI countries (D+, Table 5). The average grades stratified by geo-cultural region show similar differences as the average for countries from the Anglosphere and Europe was B−, whereas the average for countries from Africa and the Middle East was D+ (Table 6). These findings are consistent with previous work that found positive associations between the Community and Environment indicator and socioeconomic, demographic, and geographic indicators (ie, HDI, life expectancy at birth, mean years of schooling, gross national income per capita, public health expenditure, global food security index, urban population percentage, improved drinking water coverage, and distance to equator) and a moderate to strong negative association with inequality indicators (ie, Gini index and Gender Inequality Index).²²

Government (C)

Government and public policies represent a major macroenvironmental source of influence on the PA of children and adolescents, as government policies, investments, decisions, resources, and programs can fundamentally impact directly the domains of PA (eg, establishing a new compulsory physical education program with daily classes) and their source of influence (eg, funding a national education campaign raising awareness on the importance of PA, redesigning the urban environment with safe bike paths and more green spaces).³² The recommended grading methodology for this indicator focused on evidence of leadership and commitment, allocated funds and resources, demonstrated progress for the promotion of PA opportunities for all children and adolescents (Table 1) as well as a consensus between the Report Card team members on how much they considered their government was investing effort in supporting children’s and adolescents’ PA. To address this more subjective approach, the Report Card team from Wales created and tested a more structured methodology based on an adaptation of the HEPA Policy Audit tool version 2 (HEPA PAT v2) to grade this indicator in 2018.²⁴ The AHKGA decided to add this HEPA PAT v2 as a possible, but not mandatory, methodology to grade this indicator to test it in multiple and various settings.

Only 4 countries (Basque Country, England, Germany, and United States) could not grade this indicator. A total of 41 countries used the original methodology to grade this indicator, while 12 countries used the HEPA PAT v2 approach: 5 countries from Latin America (Argentina, Brazil, Chile, Colombia, and Uruguay), 3 countries from Asia-Pacific (Malaysia, Philippines, and South Korea), 3 countries from the Anglosphere (Ireland, Scotland, and Wales), and 1 country from Europe (Slovakia). Further work involving these 12 countries is now required to evaluate the feasibility and satisfaction with the use of this new methodology and to identify potential issues and improvements.

Government grades ranged from F (Nepal) to A (New Zealand and South Korea), followed closely by Finland and Chile (A−). The average grade for this indicator was C, and this average decreased with HDI category (Table 5). These observable disparities are consistent with previous work that found significant moderate associations between the Government indicator and several sociodemographic and geographic indicators (ie, gross national income per capita, public health expenditure, Gini Index, Gender Inequality Index, improved water coverage, and distance to the equator).²² These findings suggest that the movement to support children’s and adolescents’ PA is gaining traction, in particular in very high HDI countries, but the overall low to medium average behavioral grades emphasize that more action is needed to have a significant positive impact. Our findings are consistent with recent work showing that PA and sedentary behavior policies are better developed in high-income countries, compared with low- and lower-middle-income countries, and in countries of European and Western-Pacific regions, compared with other world regions, but globally have low to moderate comprehensiveness, implementation, and effectiveness.¹¹²

Impact of the COVID-19 Pandemic

Overall, the results reported in the present manuscript suggest that the COVID-19 pandemic adversely affected the 10 common PA indicators in most of the countries (Table 8), as well as the surveillance of PA and research activity of PA experts. Only a minority of the grades were informed by evidence generated after the official start of the COVID-19 pandemic (Table 7), so no valid comparison pre-/post-COVID-19 could be performed using the grades reported in this article.

Sedentary Behavior, followed by Organized Sport and Physical Activity, and Overall Physical Activity were the indicators that most Report Card Leaders reported as affected negatively by the COVID-19 pandemic (96%, 93%, and 89%, respectively). In an open comment section of the online survey, several Report Card Leaders justified these ratings by explaining that the COVID-19 safety measures were very strict, potentially putting completely on hold all sport activities and physical education classes at the national level, as well as restricting access to parks and playgrounds. For example, the Report Card Leader from Estonia reported that the impact of COVID-19 on PA behavioral indicators varied depending on the period of the pandemic:

1. •In March 2020, there was complete lockdown where children and adolescents stayed home, attending remote classes, while all sports were cancelled, outdoor playgrounds prohibited, and meeting with friends was not allowed.
2. •In September 2020 to May 2021, most schools and kindergartens were still on distance learning most of the time, indoor sports were not allowed, but outdoor sports in small groups were permitted, and it was possible to go outside to play with friends and use outdoor facilities.
3. •In September 2021 to May 2022, most schools were open and hosting in-person classes, and sports sessions occurred both indoors and outdoors while COVID-19 testing and vaccination became the main contingency measure.

Family and Peers and Community and Environment were the 2 indicators that were least negatively affected by the pandemic, as reported by the Report Card Leaders. Report Card Leaders from Israel reported that the pandemic had a small positive effect on the Family and Peers, School, and Community and Environment indicators as there were some increased activities within the family and in the community, and the school system made efforts to incorporate PA remotely by the education staff. In Australia, 2 of the biggest cities trialed “pop up bike lanes”—replacing one lane of car traffic as a bike lane with infrastructure separating the bike lane from other traffic. Recent evaluation data showed this initiative improved active transport particularly for families.¹¹⁵

Remaining physically active is important for children and adolescents to maintain a healthy immune system and build a strong defense against infections, to help alleviate feelings of depression and anxiety that may come with isolation from friends and peers, and to process and adjust to the new normal lifestyle and restrictions during this uncertain moment of their lives.¹¹⁶ Accordingly, the AHKGA published guidance on healthy movement behaviors for kids during the COVID-19 pandemic.¹¹⁷

Impact of War, Climate Change, Economic Change

The Report Card Leader survey findings highlight that the influence of war, climate change, and/or economic circumstances should not be neglected in global/international PA surveillance or promotion initiatives. Report Card Leaders from 14% (n = 8) of the countries participating in the Global Matrix 4.0 reported that war/local conflict was potentially affecting the PA of children and adolescents in their country. The Report Card Leader from Poland reported that the Russian invasion of Ukraine resulted in (1) hosting about 2 to 3 million refugees, which could indirectly impact access to PA opportunities in the near future; (2) reallocations of Poland’s national budget to military expense; and (3) restrictions on Russia, leading to inflation which will affect families’ budgets and consequently their access to leisure activities. Report Card Leaders from South Africa reported that political instability resulted in riots and strikes and an overall lack of safety in the country impacting transport, schools, and livelihoods, thereby indirectly affecting the PA of children and adolescents. Report Card Leaders from Colombia reported that a historical internal conflict has displaced people from their communities, limited opportunities for safe and healthy development of children, and has neglected the public health priority to create environments that promote active and healthy living.

Report Card Leaders from almost a third of the countries participating in the Global Matrix 4.0 considered that children’s and adolescents’ PA was currently affect by local climate change/climate change mitigations. Report Card Leaders from India estimated that the frequency and length of heat waves has increased substantially across India: “Summers are starting earlier in the northern regions and becoming hotter,” increasing risk to human health, and limiting children’s and adolescents’ ability to engage in PA in general. Report Card Leaders from Slovakia described that winters are getting milder/warmer, and there is less snow and ice in comparison with previous decades, limiting typical winter physical activities (eg, skiing, skating, cross-country skiing) in villages, cities, and even in the mountains, while this also potentially led to some seasonal activities (eg, cycling) becoming all-year round activities. The Report Card Leader from Slovenia detailed that as summers in Slovenia are becoming hotter and drier, pilot data from ongoing unpublished work demonstrates that children are less active during summertime and report being thirstier than their adult counterparts. Report Card Leaders from Thailand relayed that climate change has created an uncertainty in determining the rainy season, potentially constraining outdoor PA, and created extremely high fine particulate matter levels and high temperatures in summer. Air pollution is also a potential threat to PA in East Asian countries. South Korea Report Card leaders considered that the increasing number of days of worsening air pollution, particularly during warm days, discourages parents and schools to support PA among children and adolescents. The GAPPA presented pathways of action through which PA promotion could meaningfully contribute to climate-change mitigation,³² and actions such as disincentivizing driving could be a complementary strategy to maximize the effectiveness of PA promotion, in particular in settings where car dependence is high, for addressing physical inactivity, air quality issues, traffic-related deaths, and climate change.⁶⁰

Finally, more than half of the Report Card Leaders estimated that the PA of children and adolescents in their country were currently affected by local economic changes/challenges. Report Card Leaders from several countries (Botswana, Colombia, India, and South Africa) reported that most resources have always been directed toward competing priorities in terms of food security, health care, and education, and the current economic crisis seems to be widening the gap of inequality between the richest and the poorest. The Report Card Leader from Lebanon reported that since 2019, Lebanon has been going through an important economic crisis, and the Lebanese people have been solely focused on surviving.¹¹⁸ Similarly, Ethiopia’s Report Card Leader reported that economic challenges resulting in a struggle for the basic needs to survive may divert the attention of Ethiopian parents and children to engage in PA, and high inflation occurring in Ethiopia since 2021 is potentially increasing these challenges. Welsh Report Card Leaders reported that inflation is also currently at its highest level in decades in Wales, inevitably impinging on investment in PA opportunities for children and adolescents and forcing Welsh parents to select priorities for their families, potentially putting PA at the bottom of the list. A Report Card Leader from Nepal reported that with the current national economic transition, open spaces, particularly in urban areas, are diminishing, and this has reduced PA opportunities at the community level, while children have increased access to shared and personal screen devices such as television, tablets, and phones. Overall, economic challenges such as inflation are impacting a variety of countries across all HDI classifications and are expected to negatively impact the PA of children and adolescents through the reduction of their access to opportunities for PA; and low-income countries are facing upcoming additional challenges associated with economic transition such as decreasing access to green spaces, increasing pollution, the introduction of multiple screen-based devices in children’s and adolescents’ daily life, as well as the increase use of motorized forms of transportation.

Integrated Discussion

Overall, the Global Matrix 4.0 brought together 57 Report Card teams to evaluate 10 common PA indicators, involving almost 700 PA experts in the process.¹¹⁹ Further analysis is required to study the additional indicators submitted by Report Card Teams, and the AHKGA will explore the interest of adding the most popular ones in future Global Matrices. A global network map of the countries and leaders, researchers, and advocates participating in the Global Matrix 4.0, as well as a summary of AHKGA academic output and a summary of the overall impact of AHKGA efforts across multiple sectors are presented elsewhere.¹¹⁹

Even as the 57 countries participating in the Global Matrix 4.0 correspond to a 16% increase in comparison with the Global Matrix 3.0, representing 80 more indicator grades, a general decrease of INC (n = 105/18% in the Global Matrix 4.0 vs n = 121/24% in the Global Matrix 3.0) was observed. This encouraging decrease of INC and deeper analysis providing a synthesis of international trends for behavioral and sources of influence grades that occurred from 2014 to 2022 are discussed in another article, which is part of the present special issue.¹²⁰ However, the remaining high prevalence of INC and the reliance on smaller regional surveys or studies in the absence of consistently nationally representative data highlight the need for advocacy to promote regular, national surveillance of PA in children and adolescents worldwide.

Findings presented in Tables 10 and 11 highlight inequities in terms of grades and surveillance (difference in INC) across geo-cultural regions. These findings are consistent with the differences observed in aggregate indicators across HDI classifications and geo-cultural regions (Tables 6 and 7) and highlight the persistence of inequities between countries for the surveillance and promotion of PA in children and adolescents. Further inequity analysis across gender, age, area of residence, and ability levels were explored using Global Matrix 4.0 compiled data from participating countries.¹²¹ In general, children and adolescents with a disability tend to be ignored/overlooked in both PA surveillance initiatives (including in the Global Matrix national Report Cards on PA for children and adolescents)⁷ and PA promotion initiatives and policies.¹²² Actions are needed in PA research, surveillance, and promotion to develop tools ensuring the valid assessment and study of PA indicators in children and adolescents with a disability and to develop effective PA promotion targeting this specific population.

As reported in this paper, climate change is another rising concern for PA among children and adolescents at present, which will continue to threaten children’s and adolescents’ ability to engage in PA freely, especially outdoors. Furthermore, different patterns of the grades for behavioral indicators and the sources of influence by HDI shown in this paper, combined with the close link between climate change and country-level economic factors,¹²³ suggest these factors together likely influence Report Card grades and shape global PA and health inequities. To better understand such associations between macrolevel factors and PA patterns in children and adolescents worldwide, and gain potential insights into developing multilevel PA action, the patterns and relationships between economic freedom, climate culpability, and PA grades among the 57 participating countries were explored in another article of the present special issue.¹²⁴ Based on the main finding that Report Card grades are not equitable by climate culpability for each economic freedom group, it is recommended that global PA promotion strategies should consider incorporating inequities in the global political economy and climate change.

The challenges for assessing the PA behavioral indicators highlighted in the present discussion are consistent with previous work that led to a call for the development of a PA measurement instrument/protocol that would be globally accepted, harmonized, utilized, translated, and culturally adaptable.⁷ A research funding application involving several AHKGA PA experts was recently approved by the Canadian Institutes of Health Research to develop and validate a “Global Adolescent and Child Physical Activity Questionnaire (GAC-PAQ)” in a study to be implemented in 14 countries across 6 continents.¹²⁵ This initiative may bring solutions and contribute to addressing the current PA surveillance issues.

Strengths and Limitations

The Global Matrix 4.0 represents the largest synthesis of children’s and adolescents’ PA indicators to date, particularly for Active Play, Active Transportation, Sedentary Behavior, and for the 4 source-of-influence indicators. This project also identified major research and surveillance gaps and presented global priorities for each indicator. The most recurring priorities’ themes presented in Table 9 could also be used as recommendations in relevant contexts. Completing this project in the context of the COVID-19 pandemic was a massive achievement that required significant efforts from the 57 Report Card teams and from the AHKGA Board of Directors leading its development.

For all 10 common PA indicators, variation in the data informing the grades across countries was observed and transparently acknowledged and reported, requiring careful considerations of the international comparisons presented in this manuscript. Even when focusing solely on the Overall Physical Activity indicator, variation in data collection methods is a reality for all PA global surveillance initiatives that was challenged even more with the new WHO guidelines.⁷ The pragmatic and inclusive approach of using the “best available data/evidence” to inform the PA grades (which deliberately use a 5%–6% prevalence range to help accommodate comparable variations in data sources) is a strength of the Global Matrix 4.0. In the current context, limiting the participation to countries with data/evidence perfectly fitting the official benchmarks would lead to a selection bias and result in only a handful of countries (or for some indicators zero countries) being able to assign grades; hence, there would be no Global Matrix. More in-depth analyses are required to explore the effect of these variations on grades for each indicator.

As physical education represents one of the main PA domains for children and adolescents,⁹⁷ not including it as an extracted and separated behavioral indicator from the School indicator is a potential limitation of the Global Matrix model. AHKGA will explore the possibility of addressing this issue in the future Global Matrices.

An unequal distribution of participating countries across HDI classification categories and geo-cultural regions was observed in the Global Matrix 4.0, meaning that the interpretation of their comparisons should be considered carefully. There is a need for increased participation of low and medium HDI countries and countries from Africa and the South Pacific Islands to enable the Global Matrix initiative to capture a more “global” perspective. Overall, a decline in participation of low and medium HDI countries in the Global Matrix 4.0 was observed in comparison with previous Global Matrices, potentially illustrating the inherent challenges of prioritizing physical inactivity among many competing public health issues that were exacerbated by the COVID-19 pandemic in these countries.¹¹⁹ In addition, there was a general lack of representativeness of some specific child and adolescent populations (ie, children under 10, children and adolescents living in rural areas, children and adolescents with a disability, not attending public school, from indigenous populations, LGBTQ2S+ [Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, and Two-Spirit], and other visible or nonvisible minorities). This is a direct consequence of their underrepresentation in national/international surveys, studies, surveillance systems, and this is consistent with previous findings.⁷ Global harmonized efforts should be invested in building local capacity and supporting the inclusion of these specific populations in future PA surveillance systems and PA promotion actions, both nationally and internationally.

Finally, for the first time and as an experiment, the AHKGA allowed the participation of 3 autonomous communities/regions (Basque Country, Extremadura, and Region of Murcia) within a country also producing a national report card (Spain). This initiative allowed different communities/regions to carry out a more local Report Card on PA that could be useful to perform a diagnostic of the research/surveillance gaps and policy/program needs at the local level. This approach permitted to the 3 autonomous communities/regions to (1) become aware of the lack of high-quality studies in this region evaluating PA and its associated factors, (2) to know the current status of the 10 common PA indicators, and (3) to compare these results with those from other autonomous communities in Spain, as well as with Spanish national results. This initiative was, however, limited by the fact that not all regions of Spain were part of it and the lack of available data at the regional level for some indicators. More time and work are needed to evaluate the impact and feasibility of this initiative.