Physical inactivity is an important global health challenge, causing more than 5 million deaths each year.1 The World Health Organization has recognized it as such and has included physical activity within major global disease prevention plans since 2004.2–5 Research on physical activity policy is relatively new with the first publications appearing in the mid-1990s.6,7 Physical activity policy development has progressed since the year 2000 at the global and national levels,3,5,8–10 but implementation of national policies has remained limited.11,12 Research on physical activity and public health relevant to developing and implementing policy and programs has also grown over recent decades so that we now have both conceptual frameworks13,14 and tools for analyzing national policy development and implementation.6,11,15–19 The Global Observatory for Physical Activity (http://new.globalphysicalactivityobservatory.com) has played an important role in developing these lines of research and collecting the data required to inform the research.
Meanwhile, certain cities have created comprehensive and robust multisectoral programs and policies supporting physical activity (active transport, recreation, education, sports, green space, climate change mitigation, and synergy with the United Nations Sustainable Development Goals) with little or no formal public health policy or leadership.20–24 National physical activity policies are especially well developed in Europe where the European Network for Health-Enhancing Physical Activity (HEPA) has provided effective information sharing, models, and cross-country support.25 Europe also has a number of excellent examples of physical activity-friendly cities with strong multisectoral local policies, programs, and infrastructure; however, only a few countries have widely and successfully implemented national programs for physical activity.11,26–28 A research group in the South of France has adapted the European HEPA Physical Activity Tool for national physical activity policy development and implementation for use at the municipal level.29 Another research group in Ireland has built upon the HEPA Physical Activity Tool to develop a multilevel assessment tool for national physical activity policy development and implementation (Physical Activity Environment Policy Index).30 Initial results from both tools demonstrate excellent feasibility and utility for better understanding policy development and implementation.30,31 The Global Observatory for Physical Activity is independently developing and evaluating a similar tool for assessing national and subnational physical activity policy development and implementation. The French studies suggest that HEPA strategy recommendations translate poorly from the national to local level, in part due to lack of funding as well as the complex multisectoral nature of many physical activity promotion strategies. However, rich multisectoral local networks may facilitate more effective HEPA policies and programs.31
The hope and goal of this small and quite interconnected community of physical activity policy researchers is to solve one of the major problems limiting progress in increasing population levels of physical activity. Despite the well-documented evidence for effective physical activity interventions and well-elucidated recommendations, policies, and plans, population levels of physical activity have remained static over recent decades.12,32 Four interconnected reasons may be at the root of this lack of progress: (1) failure to implement effective strategies; (2) poor translation of research-derived strategies to real-world practice; (3) an emphasis on nonscalable research and corollary inattention to evaluation of more scalable strategies; and (4) insufficient attention to issues of country, culture, and context. For each of these 4 failings, we will provide exemplars and propose possible solutions.
Not enough money or people applied to solving the vexing and complex problem of physical inactivity is a root cause of failed implementation of effective strategies. For a public health problem underlying 5 million deaths every year, the commitment of resources to attacking physical inactivity is laughably small. As with any important public health challenge requiring policy makers to commit substantial resources, establishing saliency and urgency is critical. To date, advocacy efforts for physical activity have not been particularly successful in this regard. Even within public health and academia, physical activity is all too often not taken seriously. However, limited resources may not be the only cause for poor implementation. Another disconnect seems equally important (Figure 1). In most countries, physical activity research and the development of recommendations, plans, and policies occur primarily within the health sector.2,4,33,34 Dissemination of these health policies tends to flow down the usual health pipelines, eventually reaching municipal or local health jurisdictions. Rarely does capacity (staff or funding) to implement these plans exist within local health agencies. In fact, even if there was capacity, other sectors such as education, sport, environment, transport, and urban planning are much better positioned to actually implement changes that will influence population physical activity levels. So, how can we solve these problems? Improved advocacy for physical activity and better engagement with other relevant sectors at both national and local levels are rather obvious solutions. However, both depend upon investing time and energy to build partnerships outside of health and framing a dialogue in which increasing opportunities for physical activity solve major problems for and from the perspective of the other sectors. Neither of these tasks are easy, but current global crises may provide opportunities. Climate change is an existential crisis forcing high-priority policy responses at all levels, and active transport (ie, more people walking and cycling) is a pragmatic part of the solution.35,36 Pandemic preparedness sits at the top of most countries’ public health priorities in the wake of the global disaster of COVID-19. Once again, increasing population levels of physical activity should be part of the strategy to blunt the impact of the next pandemic by ensuring healthier and more resilient populations.37–39
—The physical activity policy disconnect.
Citation: Journal of Physical Activity and Health 20, 6; 10.1123/jpah.2023-0071
A second important issue has been the failure to translate research on effective interventions to real-world practice. Quality school physical education and primary care-based physical activity counseling and referral are notable examples.40,41 The evidence bases for both are well and long established, but progress in making either a norm has been elusive. In both cases, physical activity is acknowledged as important but other issues are felt to be more important and more pressing. Education and health care are complex systems, and introducing multifaceted physical activity promotion strategies within these systems is inherently complicated with many potential failure points. Perhaps explicitly turning to complex systems’ methodologies can help us understand what is needed to achieve better implementation within education and health care. Another less appealing alternative is that we must temper our expectations for how much can be accomplished within these sectors. Perhaps all we can hope for is adaptation of good physical activity promotion strategies within those few examples of progressive, sympathetic, or favorably structured education and health care systems.
The conundrum of ever more research that has little or no chance of scaling up while potentially large-scale strategies are minimally evaluated has been discussed at some length.12,42 This seems to be an issue of research funding continuing to focus on evidence generation, not on complex, real-world multisectoral scale-up. The vast majority of well-designed theory-based individually targeted behavior change interventions simply do not scale-up.43 There are surprising exceptions, and perhaps we can learn from them. Few behavior change interventions have been more intensive, effective, and costly yet cost-effective than the Diabetes Prevention Project lifestyle intervention.42,44 But, shifting from individual to group focus, partnering with community-based organizations, and harnessing technology facilitated scaling the Diabetes Prevention Project up from a research study to a national prevention program.45
Finally, the most obvious barrier to turning good physical activity research and policy into effective community-based programs is the disconnect between the settings where research is conducted and where it must be applied. Over the past 30 years, we have learned that country, culture, and context are enormously important in determining what types of strategies for physical activity promotion will be effective.12,26 Research from Brazil and Colombia clearly demonstrates that a different mix of strategies and programs for physical activity promotion from that recommended in North America is needed in these countries.46,47 While much progress has been made in globalizing physical activity research, 90% of publications (“evidence”) still emanate from high-income countries while low- and middle-income countries (LMIC) that account for 90% of the global population produce only 10% of research publications.15 The solution has been obvious for some time: more contextually specific intervention research conducted in diverse LMICs by LMIC researchers.48 However, training investigators, enhancing the capacity of research universities, minimizing brain drain, mobilizing and directing funds to LMIC, and translating new research insights into policies and programs in these countries remain a challenge.
Physical inactivity is a proverbial wicked problem: multifactorial, complicated, and resistant to easy solution. But it is not an insoluble problem! Some countries and cities have made substantial commitments in health or other sectors and have seen increases in population levels of physical activity.26,35 Focusing on the solutions proposed above and committing to pragmatic research and multisectoral partnerships and strategies seem likely to get more people more active in more countries. But as was noted more than a decade ago “more of the same will not be enough.”49
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