Regular participation in physical activity is crucial for health, well-being, and optimal development of children and adolescents.1 The World Health Organization and national public health guidelines in many countries therefore recommend children and adolescents aged 5–15 years to spend 60 or more minutes in moderate-to-vigorous physical activity every day or on average across the days of the week.1,2 In Croatia, such recommendation was provided within the National Health Promotion Programme “Živjeti zdravo” (Healthy Living) led by the Croatian Institute of Public Health3 and in the recently proposed Croatian 24-hour guidelines for physical activity, sedentary behavior, and sleep.4
Despite the public health recommendations, the prevalence of insufficient physical activity in this age group remains high.5 For example, based on data from 146 countries, it was estimated that 81.0% of adolescents aged 11–17 years spend too little time in moderate-to-vigorous physical activity.6 In the same study, the estimated prevalence of insufficient physical activity among adolescents in Croatia was 76.8%.6
Low engagement of children and adolescents in physical activity is a complex public health issue. Evidence-based policies and coordinated actions by policy makers and stakeholders from different sectors at the national and subnational levels are needed to effectively promote physical activity in this population group.7,8 To inform such policies and actions, it is recommended to systematically and regularly collect, interpret, and disseminate data on physical activity and associated personal, social, environmental, and policy factors, within national and international health surveillance systems.9,10
The Global Matrix was established, with the aim to facilitate and harmonize processes of gathering and assessment of data relevant to physical activity promotion among children and adolescents internationally.11 National representatives in this initiative are commonly public health researchers, who, in collaboration with other stakeholders in physical activity promotion (eg, representatives of relevant governmental bodies), conduct a comprehensive evidence review and assign grades to the following 10 standardized indicators: (1) overall physical activity, (2) organized sport and physical activity, (3) active play, (4) active transportation, (5) sedentary behavior, (6) physical fitness, (7) family and peers, (8) school, (9) community and environment, and (10) government.5
Since its first launch in 2014, 3 sets of Global Matrix report cards have been published. The current (fourth) Global Matrix includes 57 countries from 6 continents.5 Given that the last comprehensive review of evidence on physical activity among Croatian children and adolescents was conducted nearly a decade ago,12 there is a need to identify and summarize recent evidence in this area. Public health researchers and promoters from Croatia have therefore joined the Global Matrix in 2021, to contribute to the fourth set of national report cards. In this paper, we presented detailed findings of an evidence review performed to inform the Croatian Global Matrix 4.0 report card. This manuscript is the main report of the Croatian Global Matrix 4.0 grades. A summary report for Croatia can be found on the Active Healthy Kids Global Alliance website.13
Methods
This study was conducted in accordance with the standardized Global Matrix 4.0 protocol.5
Indicators and Benchmarks
All 10 abovementioned indicators were considered.5 The proposed benchmarks for each of the indicators were slightly adapted, to better align with the Croatian context and to take into account the (non)availability of respective data. The indicators and benchmarks are listed in Supplementary Table S1 (available online), together with the methods used for their assessment.
Expert Panel
A panel of 18 experts (Ž.P., Me.S., T.M., Ma.S., S.Š., I.D., M.R., B.R., H.P., H.R., J.Č., S.M.M., M.L.M., S.K., M.M., A.P., N.M., and D.J.) was formed to review the available evidence and provide ratings for each of the Global Matrix indicators. The panel members were selected purposively from the key organizations for physical activity research and promotion in Croatia. They covered the following areas of expertise: physical activity and sedentary behavior research, physical activity and public health promotion, school sports, physical education, management and funding of sports associations, and governance in the sports sector.
Literature Review
Literature Search
A systematic search was conducted in Hrčak, PubMed/MEDLINE, Scopus, SPORTDiscus (accessed through EBSCOhost), and Web of Science Core Collection (including Arts & Humanities Citation Index, Book Citation Index, Conference Proceedings Citation Index, Current Chemical Reactions and Index Chemicus, Emerging Sources Citation Index, Science Citation Index Expanded, and Social Sciences Citation Index) for any type of document published from January 1, 2012, to December 31, 2021. The Global Matrix protocol recommends to collect evidence from approximately past 5 years.11 Given that this was the first involvement of Croatia in Global Matrix, we expanded the time frame to the past 10 years, to capture any additional relevant studies and enable assessment of time trends. A search update was conducted on April 15, 2022, in the same databases, to also include the most recent relevant publications.
The search was conducted through titles, abstracts, and keywords of indexed documents using the following search terms: “physical activity,” “physical inactivity,” “physically inactive,” “energy expenditure,” exercise, sport*, “motor activity,” walking, cycling, stair*, “active travel,” “active transport,” sedentar*, sitting, “watching TV,” “TV watching,” “TV viewing,” television, “video watching,” “watching video,” “computer use,” “internet use,” gaming, “video games,” “social media,” “screen time,” lifestyle, leisure, “active play,” outdoor*, park*, Eurofit, fitness, “motor skills,” balance, tapping, speed, “sit-and-reach,” flexibility, “broad jump,” “motor skills,” “long jump,” power, handgrip, strength, “sit-ups,” endurance, “bent arm hang,” “agility,” “shuttle run,” aerobic, and anaerobic combined with child*, adolescen*, student*, pupil*, youth, teen*, kids, parent*, family, families, peers, mother*, father*, sibling*, brother*, sister*, guardian*, caregiver*, “care-giver,” friend*, colleague*, school*, community, environment, social, policy, policies, government*, budget, fund*, financ*, infrastructure, “urban design,” “neighbourhood safety,” “neighborhood safety,” “street safety,” sidewalk*, trail*, path*, lane*, “bike racks,” walkability, facility, facilities, playground*, gym, gymnasium*, and Croat*. To identify relevant literature published in the Croatian language, the search in Hrčak was performed using the search terms translated to Croatian. Search syntax can be found in Supplementary File S1 (available online).
We also screened reference lists of all included studies, conducted a comprehensive search on Google (Supplementary File S1 [available online]), and checked our personal files for any additional relevant studies that may have been missed in the search through bibliographic databases. In addition, to identify national- and county-level policies and programs, we searched the official gazette of Croatian Government and official websites of all Croatian Counties for any mentions of physical activity.
Study Selection
Study selection was performed independently by 2 authors (D.J. and Ž.P.) using a predefined EndNote X9 (Clarivate) library template. All disagreements were resolved through discussion between the 2 authors. The studies meeting the following eligibility criteria were included: (1) The study was conducted among (or in relation to) children and/or adolescents within the age range of approximately 5–15 years who were residents of Croatia, (2) the study sample was not drawn from a clinical population, and (3) the study included data that could inform any of the 10 Global Matrix indicators.
Data Extraction
The extraction of data from the included studies was performed by 4 authors (D.J., M.S., T.M., and Ž.P.). From each of the studies, we extracted information on publication year, study sample, measures relevant for this review, and key findings. We also noted which of the benchmarks listed in Supplementary Table S1 (available online) were informed by each study. Two authors (D.J. and Ž.P.) checked all the extracted data to ensure consistency and accuracy. When deemed necessary, authors of the included studies were contacted with a request to provide additional data that were not presented in the published papers. Furthermore, data from governmental policies and websites were extracted by one author (M.S.) and checked by 2 authors (D.J. and Ž.P.).
Secondary Data Analyses
To obtain additional information that was needed to assign grades to the indicators, we conducted secondary analyses of data from 6 studies: (1) the Croatian Physical Activity in Adolescence Longitudinal Study (CRO‐PALS),14–18 (2) the European Health Interview Survey (wave 2),19 (3) an ongoing PhD research project entitled “Relationship Between Determinants of Work and Physical Education Quality in Primary Education,”20 (4) the Special Eurobarometer 472 (Wave EB88.4; Sport and Physical Activity) survey,21 (5) the Sports Club for Health (SCforH) 2016/17 and 2021/22 surveys conducted as part of the projects “Promoting National Implementation for Sports Club for Health Programmes in EU Member States” (SCforH 2015–17) and “Creating Mechanisms for Continuous Implementation of the Sports Club for Health Guidelines in the European Union” (SCforH 2020–22),22,23 and (6) a PhD research project entitled “Physical Activity and Motor Skills of Preschool Children in Croatia.”24 These studies were selected because their data sets were available either publicly or to the authors of this review. Details on the methods of data collection used in these studies can be found in their published protocols and in Supplementary Tables S1–S3 (available online).
Data Synthesis
The extracted data were processed in accordance with the Global Matrix grading protocol.5 For each benchmark, from the included studies we first selected the most relevant ones, where priority was given to the most recent studies conducted in national representative samples and covering a wide age range. The selection of qualitative benchmarks informing the grade for the “Government” indicator (ie, benchmarks 10.1, 10.2, 10.3, and 10.4) was guided by the Comprehensive Analysis of Policy on Physical Activity framework,7 and the data on these benchmarks were summarized narratively. Data on all other benchmarks were expressed as percentages. Grades for each indicator were proposed by 2 authors (D.J. and Ž.P.) based on the collected data. The process of assigning grades was guided by the following grading scheme: A+ (94.0%–100.0%), A (87.0%–93.9%), A– (80.0%–86.9%), B+ (74.0%–79.9%), B (67.0%–73.9%), B− (60.0%–66.9%), C+ (54.0%–59.9%), C (47.0%–53.9%), C− (40.0%–46.9%), D+ (34.0%–39.9%), D (27.0%–33.9%), D− (20.0%–26.9%), and F (< 20.0%). The members of expert panel reviewed the grades and summaries for each indicator, and the final grades were determined based on their consensus. A detailed description of the process of assigning grades can be found in Supplementary File S2 (available online).
Assessment of Study Quality
Where applicable, the methodological quality of studies included in evidence synthesis was appraised using the Newcastle–Ottawa Quality Assessment Scale (NOS) for cross-sectional studies.25 Due to the descriptive nature of evidence used in the evidence synthesis (eg, prevalence rates), the “assessment of the outcome” item of Newcastle–Ottawa Quality Assessment Scale was not applicable. The study quality was classified based on the overall score on Newcastle–Ottawa Quality Assessment Scale as follows: “low” (0–2 points), “medium” (3–5 points), or “good” (6–8 points).
Results
Search and Study Selection Results
The searches performed in bibliographic databases resulted in a total of 4368 references. After removing duplicate references, we assessed the eligibility of the remaining 2692 unique publications. Of these, 2594 were excluded based on their titles or abstracts. We then assessed full texts of the remaining 98 publications, and 74 of them met the eligibility criteria. An additional 16 studies were found in the secondary search, resulting in a total of 90 publications included in the review.14–24,26–104 Of these, 18 studies were included in evidence synthesis.14–24,34,39,47,51,62,69,70,76,81,84,90,100 The stages of search and study selection process are summarized in Figure 1. From the additional internet searches, we selected examples of key national- and county-level physical activity policies, programs, and infrastructure (Supplementary Tables S4 and S5 [available online]).
—Flowchart of the search and study selection process.
Citation: Journal of Physical Activity and Health 20, 6; 10.1123/jpah.2022-0500
Study Characteristics and Quality
Most of the included studies were conducted in relatively small samples of primary and secondary school students, parents, and teachers in one or a few Croatian counties (Supplementary Table S2 [available online]). Only 8.9% of studies were conducted in national representative samples,19,21,49,51,68–70,81 while 5.6% of studies were conducted in large national samples.39,47,72,74,91 Most of the included studies were focused on physical activity, sports participation, and sedentary behavior of children and adolescents, while 15.6% of the included studies assessed policies, infrastructure, budgets, and programs.22,23,40,41,45,57–59,64,71,76,78,84,90 Most of the studies included in evidence synthesis (83.3%) were of medium-to-high methodological quality (Supplementary Table S6 [available online]).
Overall Physical Activity
A secondary analysis of data from a study conducted in a national representative sample of 5002 primary and secondary school students (age: 11, 13, and 15 y) within the Health Behavior in School-Aged Children 2017/18 survey found that 76.1% of 11-year-old boys, 74.3% of 11-year-old girls, 73.7% of 13-year-old boys, 64.0% of 13-year-old girls, 64.8% of 15-year-old boys, and 45.5% of 15-year-old girls spent at least 60 minutes per day on at least 4 days per week in moderate-to-vigorous physical activity.81 Taking into account that: (1) the percentage of boys and girls with physical activity level above the threshold was between 45.5% and 76.1%, and (2) there was a significant difference in the prevalence between gender and age categories, for the purpose of international comparisons within the Global Matrix 4.0 initiative, the expert panel assigned the grade B− to this indicator (Table 1).
Global Matrix 4.0 Grades for Croatia
| Indicator | Grade |
|---|---|
| [1a] Overall physical activity (for international comparisons) | B− |
| [1b] Overall physical activity (for domestic purposes) | D− |
| [2] Organized sport and physical activity | C− |
| [3] Active play | C |
| [4] Active transportation | C− |
| [5] Sedentary behavior | D+ |
| [6a] Physical fitness (for international comparisons) | INC |
| [6b] Physical fitness (for domestic purposes) | B+ |
| [7] Family and peers | D+ |
| [8] School | B− |
| [9] Community and environment | B− |
| [10] Government | D+ |
A study conducted in a national representative sample of 5169 primary and secondary school students (age: 11, 13, and 15 y) within the Health Behavior in School-Aged Children 2017/18 survey found that 30.9% of 11-year-old boys, 25.1% of 11-year-old girls, 27.5% of 13-year-old boys, 21.6% of 13-year-old girls, 21.4% of 15-year-old boys, and 13.0% of 15-year-old girls spent at least 60 minutes per day in moderate-to-vigorous physical activity.81 Compared with results from the same survey conducted in 2013/14,51 the prevalence of sufficient physical activity decreased among boys and remained similar among girls. Taking into account that: (1) the prevalence of sufficient physical activity was very low among both boys and girls, (2) there was a significant difference in the prevalence between genders, and (3) the prevalence decreased among boys over the past 4 years, for domestic purposes and in accordance with the physical activity guidelines issued by the Croatian Institute of Public Health,3 the expert panel assigned the grade D− to this indicator.
Organized Sport and Physical Activity
A study conducted in a national sample involving 25,274 parents of grade 5 and grade 7 primary school students and 5169 grade 4 secondary school students found that the prevalence of participation in organized sports activities in 2020 was 54.0% among primary school students and 30.0% among secondary school students.39 In a secondary analysis of data from a study conducted among 809 preschool children from Osijek, Rijeka, Split, and Zagreb macroregions (age: 5–7 y) in 2018/19,24 we found a prevalence of participation in organized sports activities of 59.2%. Based on data for the year 2022 provided by the Croatian School Sport Federation, it was estimated that 38.6% of primary and secondary school students are members of school sports clubs. In a secondary analysis of data from the CRO‐PALS study conducted in 2014 among 844 grade 1 secondary school students (mean [SD] age: 15.6 [0.4] y),14–18 we found that 54.0% of boys and 35.0% of girls participated in competitive or noncompetitive sports or sports clubs outside their school. Based on data for the year 2022 provided by the Croatian Ministry of Tourism and Sport, it was estimated that 21.9% of primary and secondary school students are registered as athletes. Taking into account that: (1) more than 50.0% of preschool and primary school students participated in organized sports activities; (2) there were significant differences in participation rates between preschool, primary school, and secondary school students, as well as between preschool boys and girls; and (3) the rate of participation in school sports clubs and the percentage of registered athletes in these age groups were around 40.0% and 20.0%, respectively, and the expert panel assigned the grade C− to this indicator.
Active Play
A study conducted in a national sample involving 25,274 parents of grade 5 and grade 7 primary school students and 5169 grade 4 secondary school students in 2020 found that 40.3% of primary school students and 22.3% of secondary school students participated in recreational, nonorganized physical activity on at least 4 days per week.39 A study conducted in a national representative sample including 2711 children (age: 8–8.9 y) as part of the European Childhood Obesity Surveillance Initiative, Croatia (CroCOSI), in 2018/19 found that 54.2% and 90.2% of children spent at least 2 hours per day in active play on weekdays and weekend days, respectively.70 A CroCOSI study conducted in a national representative sample of 4405 primary school students (age: 6–11 y) in 2015/16 found that 91.7% of children spent at least 1 hour per day in active play outdoors.69 A study conducted among 1121 parents of kindergarten and preschool children (mean [SD] age of children: 4.0 [1.7] y) in 2020 found that 67.9% of children spent more than 2 hours per day playing outdoors.34 A study conducted in 2021 among 162 parents or guardians (91.4% females) found that 21.0% of kindergarten and preschool children spent more than 3 hours per day outdoors.100 Taking into account that: (1) the percentages varied across the benchmarks from very low to very high, and (2) there seems to be a significant difference in participation rates between the age groups, the expert panel assigned the grade C to this indicator.
Active Transportation
The CroCOSI study conducted in a national representative sample including 2711 children (age: 8–8.9 y) in 2018/19 found that 50.0% and 55.4% of children actively commuted to and from school, respectively.70 The earlier CroCOSI study (2015/16) that was conducted in a national representative sample of 4405 primary school students with a somewhat wider age range (age: 6–11 y) found that 70.0% of children actively commuted to and from school.69 In a secondary analysis of data from the CRO‐PALS study conducted in 2014 among 844 grade 1 secondary school students (mean [SD] age: 15.6 [0.4] y),14–18 we found that 29.0% of boys and girls actively commuted to and from school. Taking into account that: (1) the percentage of active commuters varied between age groups from 29.0% to 70.0%, and (2) there seems to be a significant difference in the prevalence of active commuting between primary and secondary school students, the expert panel assigned the grade C− to this indicator.
Sedentary Behavior
In a secondary analysis of data from a study conducted among 809 preschool children from Osijek, Rijeka, Split, and Zagreb macroregions (age: 5–7 y) in 2018/19,24 we found that 25.7% of children spent less than 2 hours per day in front of the screen. The CroCOSI study conducted in a national representative sample of 4405 primary school students (age: 6–11 y) in 2015/16 found that 47.6% of children spent less than 2 hours per day in front of the screen.69 A study conducted in a national representative sample of 5169 primary and secondary school students (age: 11, 13, and 15 y) within the Health Behavior in School-Aged Children 2017/18 survey found that 53.9% of 11-year-old boys, 61.1% of 11-year-old girls, 37.3% of 13-year-old boys, 37.3% of 13-year-old girls, 38.2% of 15-year-old boys, and 42.5% of 15-year-old girls spent less than 2 hours per day in front of the screen.81 Taking into account that the percentage of preschool children who spend less than 2 hours in front of the screen was very low, while across different age groups of primary and secondary school children this percentage varied between 37.3% and 61.1%, the expert panel assigned the grade D+ to this indicator.
Physical Fitness
In the systematic review of literature, we did not find any published study conducted in a national sample since 2012 that reported data on flamingo balance, plate tapping, sit-and-reach, standing broad jump, handgrip strength, sit-ups in 30 seconds, bent-arm hang, 10 × 5-m agility shuttle run, or 20-m shuttle run tests separately for age-by-gender groups. Therefore, for the purpose of international comparisons within the Global Matrix 4.0 initiative, the expert panel assigned the grade INC to this indicator.
In a national sample of 22,135 adolescents (age: 11–18 y), 78.9% of participants were in the “fit zone” according to their results in the standing broad jump test.47 In a sample of 595 adolescents (age: 15–18 y), 74.0% of participants were in the “fit zone” according to their results in the 20-m shuttle run test.47 Therefore, for domestic purposes, the expert panel assigned the grade B+ to this indicator.
Family and Peers
In a secondary analysis of data from the Special Eurobarometer 472 survey conducted in 2017,21 we found that 4.9% of parents and guardians facilitated physical activity and sport opportunities for their children by volunteering in the sports sector, 27.6% of parents and guardians acted as role models for their children by exercising or playing sports at least once a week, and 32.6% by engaging in other types of physical activity (eg, cycling for transport and gardening). In a secondary analysis of data from the European Health Interview Survey (wave 2) survey,19 20.3% of adult family members (in families with children and adolescents) acted as role models by playing sports, exercising, or engaging in recreational activities at least once a week and 35.3% by cycling for transport at least once a week. According to the CRO‐PALS survey conducted in 2014 among 844 grade 1 secondary school students (mean [SD] age: 15.6 [0.4] y), 92.0% of boys and 90.0% of girls were supported by their parents or guardians to be physically active.14–18 Based on data for the year 2022 provided by the Croatian School Sport Federation, it was estimated that parents of at least 38.6% of primary and secondary school students supported their child’s membership in a school sports club (as evidenced by their signed consent for their child’s membership in a school sports club). A study conducted among 1121 parents of kindergarten and preschool children (mean [SD] age of children: 4.0 [1.7] y) in 2020 found that 56.2% of parents and guardians were physically active with their kids.34 Taking into account that the percentages across benchmarks varied from very low to very high, with most of them being between 20.0% and 40.0%, the expert panel assigned the grade D+ to this indicator.
School
As confirmed by the national Education and Teacher Training Agency, all students are offered the mandated amount of physical education. The agency also confirmed that all (or nearly all) students in grades 5 to 8 of primary school and in secondary school are taught by physical education teachers (ie, physical education specialists). Students in grades 1 to 4 of primary school are not taught by physical education teachers. This is a potential issue, because in our secondary analysis of data collected among 1598 grades 1 to 4 primary school teachers (who were not physical education teachers),20 we found that only 5.6% of them felt fully competent to teach physical education. Furthermore, based on data for the year 2022 provided by the Croatian School Sport Federation, it was estimated that at least 68.0% of primary and secondary schools in Croatia have a school sports club, which is an indicator of their “active” school policy and that they offer physical activity opportunities to their students beyond the mandated physical education classes. According to a report from the State Audit Office, Republic of Croatia, in 2016, 78.3% of schools in Croatia had their own gymnasium or had access to a gymnasium.90 However, only 69.5% of the gymnasiums met the national standards.90 Taking into account that: (1) there is a large difference between grades 1 and 4 of primary school and the remaining grades in the engagement of physical education specialists in teaching physical education (0.0% vs 100.0%, respectively), and (2) the percentages for most of the remaining benchmarks ranged from 68.0% to 78.0%, the expert panel assigned the grade B− to this indicator.
Community and Environment
In a secondary analysis of data from the Special Eurobarometer 472 survey conducted in 2017,21 we found that 43.6% of parents and guardians of children aged 5–15 years perceived that their local authorities are doing enough for their residents in relation to physical activity, 57.8% thought that the area where they live offers many opportunities to be physically active, and 55.5% thought that their local sports clubs and other local providers offer many opportunities to be physically active. In a secondary analysis of data from another study,24 we found that 80.1% of parents and guardians of children aged 5–7 years thought that the conditions for child free play and recreation in their neighborhood are adequate. In our analysis, we found that all 21 Croatian counties have policies/programs and infrastructure for the promotion of sport and physical activity (Supplementary Table S5 [available online]). In a study conducted among 211 parents of primary school students in Rijeka, 54.1% of participants were satisfied with the quality of sidewalks, but only 13.2% were satisfied with the quality of bike paths.62 In the same study, 41.7% of parents perceived their child’s routes to school, including sidewalks and bike lanes, safe for active commuting, while 54.5% of them reported that their children perceive the routes to school safe for active commuting.62 Taking into account that: (1) all Croatian counties have policies/programs and infrastructure for the promotion of sports and physical activity, and (2) that most aspects of community and environmental support to physical activity were perceived positively by 40.0% to 60.0% of parents and children, the expert panel assigned the grade B− to this indicator.
Government
Several Croatian national policies refer to physical activity and sports promotion (Supplementary Table S4 [available online]). The most comprehensive policy in this regard is the National Sports Program 2019–2026. Some of the policies refer specifically to children and adolescents, which indicates the commitment of the national government to providing physical activity opportunities for the members of these age groups. However, there are currently no standalone “national physical activity strategy” and “national action plan for physical activity.” In our secondary analysis of data from the SCforH projects,22,23 the commitment of the national government to the promotion of health-enhancing physical activity as perceived by sport and public health stakeholders was moderate; the average score on the scale from 0 to 10 was 4.51. In 2019, 0.2% of the national budget was allocated to sports.84 It seems that more emphasis could be put specifically on the promotion of health-enhancing physical activity, including sports-for-all.76 The National Health Promotion Programme “Healthy Living” has been endorsed by the national government and implemented by the Croatian Institute of Public Health since 2015. The activities of this comprehensive, multidisciplinary program are implemented at the local community level with the aim to improve awareness and knowledge of healthy lifestyles and create healthier environments for the entire population, including children and adolescents. Furthermore, the “European Week of Sport” (#BeActive) initiative has been implemented annually by the Ministry of Tourism and Sport since 2015. Both of the programs are nationwide and include participants from all age groups, which demonstrates progress through stages of policy cycle. Therefore, the expert panel assigned the grade D+ to this indicator.
Discussion
Key Findings
The key finding of our study is that several aspects of physical activity promotion among children and adolescents in Croatia should be improved. An emphasis should be placed on (1) increasing physical activity, particularly among girls; (2) reducing sedentary screen time, particularly among boys; (3) improving parental support to children’s physical activity; and (4) further development of national physical activity policies. Key expert panel recommendations for physical activity promotion in Croatia are listed in Table 2.
Key Expert Panel Recommendations for Physical Activity Promotion Among Children and Adolescents in Croatia
| Overall physical activity |
| 1. Reverse the trend of decline in physical activity. |
| 2. Place focus on physical activity promotion among girls. |
| 3. Prevent a decline in physical activity in the transition from primary school to secondary school. |
| Organized sport and physical activity |
| 1. Prevent a decline in participation in organized sport and physical activity in the transitions from preschool to primary school and from primary school to secondary school. |
| 2. Place focus on the promotion of organized sport and physical activity among girls. |
| 3. Increase the participation of primary and secondary school students in school sports clubs. |
| Active play |
| 1. Prevent a decline in participation in recreational, nonorganized physical activity in the transition from primary school to secondary school. |
| 2. Increase participation in active play on weekdays. |
| 3. Increase the time spent outdoors. |
| Active transportation |
| 1. Promote active transportation among both primary and secondary school students. |
| 2. Prevent a decline in using active transportation in the transition from primary school to secondary school. |
| 3. Improve monitoring of active transportation among preschool children. |
| Sedentary behavior |
| 1. Focus on reducing sedentary screen time among preschool children. |
| 2. Prevent an increase in sedentary screen time in the transition from primary school to secondary school. |
| 3. Focus on reducing sedentary screen time among boys. |
| Physical fitness |
| 1. Maintain high levels of aerobic and muscular fitness. |
| 2. Assess other aspects of physical fitness. |
| 3. Establish a national surveillance system for physical fitness among children and adolescents. |
| Family and peers |
| 1. Increase the involvement of parents of children and adolescents in volunteering in the sports sector. |
| 2. Promote physical activity among parents of children and adolescents, to improve their physical activity role modeling. |
| 3. Maintain the high prevalence of parents who support their children to be physically active. |
| School |
| 1. Increase the competencies of grades 1 to 4 primary school teachers (not physical education teachers) for teaching physical education. |
| 2. Increase the number of schools with their own (or access to) gymnasiums that meet national quality standards. |
| 3. Increase the number of schools that have school sports clubs. |
| Community and environment |
| 1. Improve the opportunities for children and adolescents to engage in physical activity in their local areas. |
| 2. Improve the quality and safety of built infrastructure for active transportation, especially bike paths. |
| 3. Maintain the county-level policies, programs, and infrastructure that effectively support physical activity. |
| Government |
| 1. Develop standalone national physical activity strategy and national physical activity action plan. |
| 2. In the national budget, put more emphasis specifically on the promotion of health-enhancing physical activity, including sports-for-all. |
| 3. Increase participation rates in national programs and initiatives for the promotion of physical activity. |
Overall Physical Activity, Organized Sport, Active Play, and Active Transportation
The percentage of boys and girls in Croatia who spent at least 60 minutes per day in moderate-to-vigorous physical activity was rather low, similar to the estimated global average.6,81 This is concerning, because physical activity in this age is associated with a range of health benefits, such as improved cardiometabolic health, physical fitness, adiposity status, bone health, cognitive skills, mental health, and academic achievement.105 It should, therefore, be a public health priority in Croatia to increase physical activity level of children and adolescents. This may be indirectly achieved through improvements in all the remaining Global Matrix 4.0 indicators. Some possible strategies that could be used for this purpose are presented herein, as part of the discussion about each of the indicators. More details about interventions to increase physical activity among children and adolescents can be found in recently published umbrella reviews on this topic.106,107 In addition, comprehensive recommendations for physical activity promotion developed in other countries (eg, Australia8) could be used as a source of ideas for the development of specific strategies in Croatia.
The decline in physical activity among Croatian boys over time was also in accordance with international findings.6,49,51,81 Unlike girls, it may be that boys are becoming more and more susceptible to replacing their physical activity with screen time (eg, computer use), which would explain the downward trend in their physical activity. This is supported by previous studies that found larger temporal increases in computer use and overall screen time among boys, compared with girls.108,109 To prevent a further decline in physical activity among boys, it may be needed to simultaneously address their sedentary behavior.
In Croatia, participation in physical activity and organized sports seems to be lower among girls than among boys.14–18,81 This could be explained by the negative influence of gender roles and stereotypes on sports and exercise participation among girls.110,111 For example, a recent Croatian study112 found that around 95.0% of adolescent handball players encountered some form of gender stereotypes related to sports participation (eg, “sport is not for girls” and “female sport is less attractive than male sport”), with girls being significantly more exposed to such stereotypes than boys. Therefore, eliminating factors that lead to gender inequality and discrimination in sports may be needed to increase girls’ physical activity. The difference in physical activity between boys and girls in Croatia increases with their age. Furthermore, physical activity decreased with age in both genders, but it seems it declines faster among girls. It is possible that this is related to earlier biological maturation of girls, compared with boys.113–115 The difference between genders in maturation timing may, therefore, partially explain lower physical activity found among Croatian girls.
Children in Croatia engaged more in active play on weekends than on weekdays.70 This might be because of a compensatory effect,116 that is, due to higher involvement in other physical activities (eg, sports, physical education, and active transport) on weekdays, they reduce their involvement in active play. However, it may also be because of a lack of time and opportunities for active play within and outside the school setting. Children engage in active play to have fun, prevent boredom, gain physical and mental health benefits, and exercise their autonomy from adults.117 Active play is therefore considered as an important health behavior and developmental activity.118 To facilitate more active play on weekdays, parents and educators should allow enough unstructured time to children, while local governments and schools should create environments that support nonorganized physical activity.
Lower rates of participation in organized sport and active transportation among Croatian secondary school students, compared with primary school students, are in accordance with findings from other countries.119–122 The decline in sports participation may partially be due to dropout of children from sports clubs that commonly occurs as a result of talent selection in sports around this age. In regard to active transportation, children in Croatia usually attend primary schools on a walking distance from home, while their secondary schools are often located more distantly. This may be a reason for the switch from active to passive modes of transport in the transition from primary to secondary school. Furthermore, unlike a recent Australian study,120 we also found an age-related decline in participation in active play/nonorganized physical activity and overall physical activity. To prevent the decline in physical activity in the transition from primary school to secondary school, various interventions may be needed across different sectors. For example, according to the SCforH guidelines,123 inclusion needs to be facilitated in the sports sector by enabling boys and girls of all ages and skill levels to start participating and remain involved in their preferred sports. In the transport sector, improving cycling lanes would likely increase active commuting, particularly to and from secondary schools. The education sector could also contribute to physical activity promotion among secondary school students, by making the school gymnasiums accessible outside school hours, and especially during weekends.
Sedentary Behavior
Nearly 3 out of 4 preschoolers and around half of school-age children and adolescents in Croatia spend more than 2 hours per day in front of the screen, which is in line with findings from other countries.124,125 The high prevalence of excessive screen time is concerning because of its association with poorer cardiometabolic health, physical fitness, adiposity status, mental health, and social behavior in this population.105 It should, therefore, be a public health priority in Croatia to reduce the amount of sedentary screen time among children and adolescents, with a focus on preschool children. A particularly important role in this endeavor should have parents and families. Effective strategies for their influence on children’s sedentary behavior have been elaborated elsewhere.126
It seems that the amount of screen time drops when children in Croatia start primary school and then increases during or sometime before their transition to secondary school. The increase in sedentary time around the transition to secondary school coincides with the decrease in physical activity. Possible reasons for this could be the switch from active to passive modes of transport and an increased amount of sedentary education time within and outside school hours. Adolescents often use computers for learning and mobile phones in public transport, which could explain the increase in sedentary screen time. Among all possible reallocations of time between movement-related behaviors (ie, physical activity, sedentary behavior, and sleep), increasing sedentary behavior at the expense of moderate-to-vigorous physical activity seems to have the most detrimental consequences for health and well-being.127 It is, therefore, important to prevent the increase in sedentary behavior in the transition from primary to secondary school, while concomitantly trying to maintain or increase the level of moderate-to-vigorous physical activity.
In Croatia, the prevalence of excessive screen time was higher among boys than among girls.81 Previous research on different types of sedentary behavior found that the largest difference between genders was in the amount of time spent playing video game consoles, with the figure for boys being twice as high as for girls.125 There is a range of effective interventions to reduce sedentary screen time among children and adolescents, but it seems that one size does not fit all.128 To effectively reduce sedentary screen time among boys, Croatian public health authorities should tailor the intervention content to their specific needs and interests. For example, active video games may increase physical activity and improve some aspects of health while being perceived by boys as an “acceptable” replacement for sedentary screen time.129,130
Physical Fitness
Around 3 out of 4 Croatian adolescents were in the “fit zone” according to their results in the standing broad jump test and 20-m shuttle run test,47 which could suggest a relatively high level of their fitness. However, several limitations have to be taken into account when interpreting these findings. First, the tests were performed more than 10 years ago, which means that the results do not necessarily reflect the current fitness levels of Croatian adolescents. Second, these findings only refer to 2 measures of fitness, while for other standard tests, such as flamingo balance, plate tapping, sit-and-reach, handgrip strength, sit-ups in 30 seconds, bent-arm hang, and 10 × 5-m agility shuttle run, we did not find national representative data. It might be that other fitness tests would show different results. Third, the data were available for adolescents only; hence, no inference can be made about fitness levels of children. To overcome these limitations, a national surveillance system for physical fitness among children and adolescents should be established. Given that a range of standardized fitness tests are already conducted at least 3 times per year in all Croatian schools, such a surveillance system would only require to establish additional protocols for: (1) uploading data from individual schools to a central database, (2) accessing the raw data, (3) central analysis and interpretation of the data, and (4) dissemination of findings.
Family and Peers
We found that a large number of parents in Croatia provide “passive” support for physical activity to their children (eg, verbal encouragement to be physically active and providing consent for their child to get enrolled in a sports club), while volunteering in the sports sector and role modeling are much less prevalent. Volunteering in the sports sector in Croatia seems to be several times less represented than in some other European countries such as Denmark, the Netherlands, Norway, and Switzerland.131 By volunteering in sports clubs and events, parents may contribute to increasing the national capacity for physical activity promotion in Croatia. For example, this may create more opportunities for children to engage in sport. Also, the money saved by not having to pay for their volunteer work can be invested in other important aspects of physical activity promotion. Parents in Croatia should, therefore, be encouraged to volunteer in the sports sector. Furthermore, previous studies found that parental role modeling is positively associated with children’s physical activity levels.132 Hence, parents should also be encouraged to act as role models by regularly engaging in physical activity on their own or together with their children.
School
In Croatia, all primary and secondary schools offer the mandated amount of physical education (eg, 3 × 45 min/wk in grades 1–3 and 2 × 45 min/wk in grades 4–8) to their students, and most schools also offer extracurricular sports activities, which is similar as in several other European countries.78 Increasing the number of physical education classes per week could help students in Croatia to meet the physical activity recommendations. However, before such a change in the school curriculum is made, it should be explored whether the students would compensate for the increase in physical education by reducing their involvement in other physical activities.
The quality of physical education classes in Croatia is likely compromised by: (1) low perceived competence for teaching physical education among grades 1 to 4 primary school teachers, (2) a large number of schools without access to a gymnasium, and (3) a large number of school gymnasiums that do not meet the national quality standards. Therefore, the Ministry of Science and Education should explore possible ways to increase the number of quality school gymnasiums and improve the formal education and professional development of grades 1 to 4 primary school teachers.
Community, Environment, and Policy
Although Croatia has a number of national- and county-level physical activity policies and programs, many children and adolescents still lack adequate opportunities to be physically active in their local areas. To improve the capacity for physical activity promotion in Croatia, the national government should explore options to develop standalone “national physical activity strategy” and “national action plan for physical activity.” These documents are needed, as they would enable to detail the key elements for successful national policy approach to physical activity promotion, such as supporting evidence, goals, targets, time frames, funding, actions, implementation plans, and evaluation methods.133 They would also allow to integrate and/or coordinate physical activity promotion actions across different sectors, including education, environment, health, public finance, recreation and leisure, research, sport, tourism, transport, urban/rural planning and design, and work/employment.7 Counties and local governments should make further improvements in accessibility and quality of their infrastructure for physical activity, such as sports gymnasiums, recreational facilities, parks, footpaths, and bike lanes. Physical activity promotion among children and adolescents in Croatia could also be supported by increasing participation rates in ongoing national public health programs and initiatives such as the National Health Promotion Programme “Živjeti zdravo” (Healthy Living) and the “European Week of Sport” (#BeActive).
Comparison With Other Countries
Among 57 countries/economies/states/territories (hereafter referred to as “countries”) included in the Global Matrix 4.0, Croatia scored particularly well in the “overall physical activity” indicator; it was in the top 15.0%.5 According to all other indicators, Croatia was ranked among the bottom 50.0% of the countries. According to the overall rank (calculated from the sum of ranks for all indicators), Croatia was ranked number 32 out of 57 countries included in the analysis.
Among 38 high-income countries included in the analysis, Croatia was placed in the top 20.0% according to the “overall physical activity” indicator, and in the bottom 50.0% according to all other indicators.5 Overall, Croatia was ranked number 25 out of 38 high-income countries included in the analysis. It is an encouraging finding that in comparison with other countries Croatia stands relatively well according to the key indicator. The relatively low rankings in the remaining indicators should motivate policy makers and other public health stakeholders in Croatia to increase investments in physical activity promotion.
Strengths and Limitations of the Study
The main strengths of our study were as follows: (1) the systematic literature search conducted in 5 bibliographic databases using a comprehensive set of 100 keywords, (2) the large number of included studies (n = 90), (3) 6 secondary data analyses that were conducted to obtain additional, relevant information, and (4) the large team of experts from different sectors who were involved in assigning grades to the indicators.
This study has several limitations. First, the availability of data for some indicators was limited. For example, we could not find national representative data on active transportation among preschool children. We also could not find national representative data for fitness status other than for 2 exercise tests. Second, data from different studies included in our review may not necessarily be directly comparable. A comprehensive physical activity surveillance system9 may be needed to improve availability and comparability of data relevant to Global Matrix indicators in Croatia. Such a system would also make it easier to evaluate progress in the indicators over time. Third, not all studies included in evidence synthesis were of high methodological quality. Croatian studies on this topic could generally be improved by: (1) reporting response rates, (2) using sample weights to increase the generalizability of estimates, and (3) presenting confidence intervals for percentages to enable statistical inference. Fourth, certainty of evidence was not assessed because of the wide range of outcomes for which the evidence was reviewed and summarized. Fifth, in the process of assessing the “Government” indicator, it was beyond the scope of this review to analyze all relevant elements of the Comprehensive Analysis of Policy on Physical Activity framework. Alternative methodologies for assigning Global Matrix grade to this indicator have been proposed elsewhere134 and could be considered in future studies. Finally, the review protocol was not preregistered. However, we followed the standardized Global Matrix 4.0 protocols.
Conclusions
There is a high prevalence of insufficient physical activity and excessive screen time among children and adolescents in Croatia. Coordinated actions should be taken across different sectors to improve physical activity promotion, with a focus on increasing physical activity among girls, reducing sedentary screen time among boys, improving parental support for physical activity, and further development of national physical activity policies. This could be facilitated by: (1) preventing a decline in participation in organized sport, active play, and active transportation in the transition from primary school to secondary school; (2) allowing enough unstructured time to children to engage in active play; (3) increasing volunteering of parents in the sports sector; (4) improving parental role modeling for physical activity; (5) improving competences of grades 1 to 4 primary school teachers for teaching physical education; (6) increasing the number and quality of school gymnasiums; (7) improving the accessibility and quality of built environment for physical activity; (8) developing a standalone national physical activity strategy and physical activity action plan; (9) putting more emphasis in the national budget specifically on the promotion of health-enhancing physical activity, including sports-for-all; and (10) increasing participation rates in national physical activity programs and initiatives. Such endeavors should be guided by scientific evidence on the effectiveness of physical activity and sedentary behavior interventions and examples of good practice from other countries.
Acknowledgments
The review was conducted by following the Preferred Reporting Items for Systematic Review and Meta-analyses guidelines. The authors of the study are thankful to the Active Healthy Kids Global Alliance leadership team for their guidance and support. Author Contributions: Pedišić and Jurakić conceived the study idea and plan, performed study selection and data synthesis, drafted the manuscript, and led the correspondence with journal editors and reviewers. Pedišić conducted the academic literature search. Pedišić, Jurakić, Strika, and Matolić extracted the data from the included publications. Strika searched through and extracted data from governmental policies and websites. Jurakić, Sorić, Pedišić, and Šalaj conducted the secondary data analyses. Čvrljak, Dujić, Jurakić, Krtalić, Lang Morović, Matolić, Milić, Momčinović, Musić Milanović, Papić, Pedišić, Podnar, Radašević, Radičević, Rakovac, Sorić, Strika, and Šalaj took part in the expert panel. All authors contributed to and approved all versions of the manuscript.
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