Approximately 27.5% of adults worldwide are physically inactive, and the World Health Organization has suggested a 15% relative reduction in this prevalence by 2030.1 Consequently, over the past few decades, countries have developed and implemented national and local physical activity (PA) policies to increase population levels of PA.2 Currently, 82.9% of the world’s countries have PA included in a national policy, either as a standalone policy or within a noncommunicable disease (NCD) plan.3 PA policy and promotion has received less political support and financing than other public health priorities (eg, healthy nutrition, tobacco control, and prevention of harmful use of alcohol), leading to implementation gaps.4–7 For example, when compared with tobacco policies, the World Health Organization NCD-Global Action Plan’s midpoint evaluation from 2013 to 2019 underscored a consistent rise in their implementation in contrast to PA policies.8–11
These implementation gaps are related to the complexity of PA policies that need multisectoral approaches and must address socioecological factors at several government levels.12 Also, top-down and bottom-up procedures in parallel with vertical and horizontal communication can enhance collaboration and participation, but national policymakers frequently overlook these factors.13,14 Countries’ political, geographical, and governmental structures make multilevel governance challenging,15 and only a limited amount of information is accessible on the relationships between this array of national and local stakeholders.16 Therefore, better understanding of the interplay between levels might enhance our knowledge of government levels’ roles in policy development, implementation, and coordination (or lack thereof).17
Few global studies have examined PA policies.18 The Global Observatory for Physical Activity (GoPA!) provides evidence to encourage countries to improve their epidemiological surveillance systems and advance PA policies and initiatives to increase global PA levels.19 GoPA! analyzed country members’ national PA policy implementation in 2020 and found that most only executed half of their policies.20 More countries would be able to successfully combat physical inactivity if national and local development, implementation, and evaluation of PA policies were improved.21 Since 2019, GoPA! has aimed to develop more comprehensive PA policy indicators to contribute to the understanding of the PA policy process and cycle.18–20
A questionnaire to examine the PA policy process (described elsewhere22) was tested in Latin American countries to determine its applicability. Latin America was selected as an ideal study region since most of its countries have been classified as middle-income countries and tend to have less comprehensive, implemented, and effective policies than high-income countries.20 The region has the second-largest number of GoPA! Country Contacts (local PA experts) compared with Europe,23 and while research on PA has increased, it is not enough to address the region’s physical inactivity problem affecting one-third of Latin Americans.24 Also, the available evidence suggests that national policy development has been successful in Colombia, Costa Rica, Ecuador, and Mexico, but implementation has been slow and uncoordinated partly due to political and socioeconomic factors.25 Thus, conducting a study in Latin American countries may provide evidence of the feasibility and scalability of this study, particularly for other low- to middle-income countries. This study aimed to characterize the development and implementation process of PA policies at national and subnational levels in Colombia, Costa Rica, Ecuador, and Mexico to better understand the coordination between levels—national and local/city—across the policy process.
Methods
Study Design and Setting
An observational cross-sectional study was conducted in 4 Latin American countries and 8 of their cities: Bogotá and Bucaramanga (Colombia), San José and Nicoya (Costa Rica), Quito and Cuenca (Ecuador), and Mexico City and Cuernavaca (Mexico). Supplementary Material S1 (available online) shows the geopolitical structure of these countries.
Participants and Sample Size
GoPA! Country Contacts from Colombia, Costa Rica, Ecuador, and Mexico were formally invited to become co-investigators in the study and serve as their country’s principal investigators. Details on identification and a full list of Country Contacts can be found elsewhere.23,26
Online surveys to national and subnational government informants collected data on PA policies and the policy process stages leading to their implementation between August 2022 and February 2023. Snowball or chain-referral sampling was utilized to recruit participants, and the Country Contacts selected the sample size based on the sectors responsible for implementing PA policy initiatives at the national and subnational levels. Each local researcher recruited national and subnational informants. Two cities were selected per country; the capital city and a city where the local lead investigator was either situated or had previously conducted research and knew local government contacts. The study employed policy-related definitions from Table 1.
Policy-Related Definitions
| Term | Definition |
|---|---|
| Physical activity policies | Defined by Klepac Pogrmilovic et al18 as “Formal written policies, unwritten formal statements, written standards and guidelines, formal procedures, and informal policies (or lack thereof) that may directly or indirectly affect community- or population-level [physical activity].” |
| Policy cycle | Defined by Benoit32 and Howlett and Ramesh33 as involving 5 stages—agenda setting (process through which a problem is identified and structured as of public interest and is intended to be addressed through public policy), policy formulation (process in which public administration examines the different policy options that can be considered as possible solutions for the problem), adoption or decision making (stage during which decisions occur at a governmental level, resulting in selecting solutions for the policy), implementation (process in which the parameters for implementing the policy are established. At this same stage, objectives are set), and evaluation (process in which a policy is evaluated to assess its effectiveness concerning the policy objectives). |
| Key informants | Government contacts who have an official position that is not temporary. Therefore, people in temporary positions (eg, those per project or contract) should not be referred to as government contacts. |
| Policy implementation | Defined by Klepac Pogrmilovic et al18,20 and Kelly et al34 as “Translating statements, ideas, goals, and/or objectives mentioned in the policy documents into practice. For example, a policy document may mention building new facilities as strategies to increase participation in physical activity. Implementation of this statement means having the new facilities built.” |
Data Collection
Questionnaire Development
The study questionnaires were developed using the following documents and frameworks as a guide: (1) the CAPLA-Santé tool,27 (2) the European Health-Enhancing Physical Activity Policy Audit Tool (version 2.0),28 (3) the Comprehensive Analysis of Policy on Physical Activity framework,18 (4) the GoPA! Policy Inventory (version 3.0),20 and (5) the Physical Activity Environment Policy Index.29 The resulting 6 questionnaires formed the “Interaction between National and Local Government Levels in Development and Implementation of Physical Activity Policies Tool” (INTEGRATE-PA-Pol)22 (see Supplementary Materials S2–S7 [available online]). The testing processes (focus groups and Cognitive Response Testing) were conducted with GoPA! Country Contacts and confirmed its robust face and content validity, along with its feasibility for application in low- to middle-income Latin American countries. Further details regarding the development, validation, and testing of the INTEGRATE-PA-Pol tool are described elsewhere.22 Data were collected with the Research Electronic Data Capture (REDCap) software30,31 using a password-protected server from Universidad de los Andes in Bogotá, Colombia.
Country’s Geopolitical Structure
This questionnaire included 3 sections: (1) political structure, (2) geographical organization, and (3) governance system.
Identification of Government Informants and Primary Sectors Involved in Developing and Implementing PA Policies
This questionnaire included 2 sections: (1) identification of the primary sectors and (2) informants’ contact information. The intended audience was the Country Contacts.
Policy Cycle Characteristics and Description
These questionnaires included 4 sections: (1) PA policies’ characteristics, (2) operational structure according to the policy cycle, (3) policy content, and (4) policy implementation. There were 4 questionnaires for informants, 2 at the national level and 2 at the subnational level. The government contact received either the health sector or other sectors’ questionnaire depending on their role.
Questionnaire Distribution
All target audiences received emails with the linked REDCap questionnaire link.30,31 Incomplete or partial replies received up to 5 follow-up emails or phone calls.
Study Variables
Policy Characteristics
Policies were examined for their roles in promoting PA at the national and subnational levels (ie, central, important but not central, or secondary) and whether they were standalone (ie, exclusive) or embedded in another policy or plan (eg, NCDs plan).
Policy Operational Structure
For national and subnational policies, informants described their engagement in the 5 policy process stages. To understand cross-government interactions, the questions asked informants about their engagement with the other level’s policy and the other level’s participation in their policy. Close-ended and open-ended questions with 5-point Likert scales were used to measure involvement and a higher score represented an extensive level of involvement. These responses were later recoded into 4 categories “high,” “medium,” “low,” and “I do not know.”
Policy Content
Settings, environments, and audiences included as relevant for implementing PA actions at the national and subnational levels were assessed with a response matrix with “yes,” “no,” “I do not know,” and “not applicable” possible answers.
Policy Implementation
National and subnational informants estimated the extent to which the current PA policies have been implemented with a ten-point Likert scale in which a higher score represents a full implementation of the policy statements. These responses were later recoded into 3 categories “fully implemented,” “somewhat implemented,” “not at all implemented.” These questions are followed by binary type questions to identify the allocation of funding for policy implementation and its funding source.
A full description of the study variables and final instrument is described elsewhere.22
Data Analysis
Descriptive analyses were conducted using STATA (version 17.0, StataCorp). Ethics approval was obtained from the Ethics Committee of Universidad de los Andes, Colombia (2022; Approval No. 20220106).
Results
The GoPA! Country Contacts identified 39 informants (see Figure 1). The retention rate was 69.2% (27 out of 39 possible eligible informants). Twenty-six completed the questionnaires leading to a response rate of 96.3%; however, 11.5% of them were missing the required data, therefore the final sample size was 23 informants. Mexico had the highest total number of informants (n = 7, 30.4%) and Costa Rica had the lowest (n = 4, 17.4%) (see Table 2). Representation for capital and second cities for all countries was achieved, except for Ecuador, where no informants could be reached for Quito (country’s capital).
—Participants’ selection flowchart.
Citation: Journal of Physical Activity and Health 21, 5; 10.1123/jpah.2023-0342
Characteristics of Informants and Physical Activity Policies at the National and Subnational Levels
| Total (N = 23) n (%) | National level (N = 9) n (%) | Subnational level (N = 14) | ||
|---|---|---|---|---|
| Capital city (n = 5) n (%) | Second city (n = 9) n (%) | |||
| Participants’ characteristics | ||||
| Country | ||||
| Colombia | 6 (26.1) | 2 (22.2) | 2 (40.0) | 2 (22.2) |
| Costa Rica | 4 (17.4) | 2 (22.2) | 1 (20.0) | 1 (11.1) |
| Ecuador | 6 (26.1) | 3 (33.3) | 0 | 3 (33.3) |
| Mexico | 7 (30.4) | 2 (22.2) | 2 (40.0) | 3 (33.3) |
| Sector | ||||
| Health | 12 (52.2) | 5 (55.6) | 3 (60.0) | 4 (44.4) |
| Sport | 6 (26.1) | 2 (22.2) | 1 (20.0) | 3 (33.3) |
| Transport | 3 (13.0) | 1 (11.1) | 1 (20.0) | 1 (11.1) |
| Education | 2 (8.7) | 1 (11.1) | 0 | 1 (11.1) |
| Position/title tenure | ||||
| Less than 1 y | 2 (8.7) | 0 | 1 (20.0) | 1 (11.1) |
| 1–3 y | 5 (21.7) | 4 (44.4) | 0 | 1 (11.1) |
| 3–5 y | 8 (34.8) | 3 (33.3) | 1 (20.0) | 4 (44.4) |
| 5 y or more | 8 (34.8) | 2 (22.2) | 3 (60.0) | 3 (33.3) |
| Policy characteristics | ||||
| Existence of a physical activity policy | 21 (91.3) | 8 (88.9) | 5 (100) | 8 (88.9) |
| Standalone physical activity policy | 7 (33.3) | 1 (12.5) | 1 (20.0) | 5 (62.5) |
| Physical activity embedded in another policy/plan | 13 (61.9) | 6 (75.0) | 4 (80.0) | 3 (37.5) |
| Noncommunicable diseases prevention plan | 6 (46.2) | 3 (50.0) | 2 (50.0) | 1 (33.3) |
| Obesity prevention and/or management or control plan | 1 (7.7) | 0 | 0 | 1 (33.3) |
| Other | 6 (46.2) | 3 (50.0) | 2 (50.0) | 1 (33.3) |
| Role that physical activity promotion plays in the policy | ||||
| Central (eg, it is an exclusive policy for physical activity) | 10 (47.6) | 1 (12.5) | 3 (60.0) | 6 (75.0) |
| Important but not central (eg, physical activity is included in another policy or plan) | 8 (38.1) | 6 (75.0) | 2 (40.0) | 0 |
| Secondary (perhaps physical activity is not mentioned; however, the document has an influence on physical activity) | 3 (14.3) | 1 (12.5) | 0 | 2 (25.0) |
More than half of the informants (52.2%) were from the health sector, followed by the sport (26.1%), transport (13.0%), and education (8.7%) sectors. No informants reported working for other sectors that might influence PA policies (ie, recreation and leisure, environment, urban/rural planning and design, tourism, work and employment, public finance, and research).18,27 Informants from the national level who had held their current post for less than 3 years made up the largest group (44.4%), followed by those who had held their position for 3–5 years (33.3%), and finally, those who had held their current position for more than 5 years (22.2%) (see Table 2). In contrast, at the subnational level, 42.9% of informants had been in their current position/title between 3 and 5 years, while 35.7% had been there for more than 5 years.
Geopolitical Organization
Countries’ internal structure, territorial organization, and subnational administration affect policy implementation (see Supplementary Material S1 [available online]15). Colombia, Costa Rica, and Ecuador share a similar internal organization (ie, unitary). Colombia has political decentralization in place (ie, authority and responsibility are distributed from the center of the country to its peripheral territories), while Mexico operates under a federal system that delegates power to independently functioning state and local administrations.15 The constitution and legislation of each country determine their subnational government, and despite having a central government, Colombia, Costa Rica, and Ecuador have semiautonomous institutions in place, and Costa Rica has autonomous institutions as well. Each nation has its own subnational territorial structure, and the 4 countries have different 3-tiered territorial divisions.
PA Policy Characteristics
Most informants from both levels reported that their countries have a PA policy being implemented (91.3%), of which 33.3% were standalone PA policies and 61.9% were embedded in other policies or plans (see Table 2). The latter included 46.2% in NCDs prevention plans, 46.2% in other plans, and 7.7% in obesity prevention/management/control plans.
At the national level, 75.0% of respondents placed the role as important but not central (eg, PA is included in another policy or plan), followed by 12.5% who placed it as having a central role, and 12.5% who placed it as having a secondary role (eg, perhaps PA is not mentioned; however, the document has an influence on PA) (see Tables 2 and 3). More than half of respondents (75.0%) at the subnational level reported that promoting PA plays a central role in their country’s policy, while 25.0% said it was important but not central (see Tables 2 and 3).
Relation Between National and Subnational Physical Activity Policies
| Country | Level | City | Sector | # | Policy title | Publication year | Timeframe | National/subnational policies relation | Perception of the role of physical activity promotion |
|---|---|---|---|---|---|---|---|---|---|
| Colombia | National | NA | Health | 1 | Ten-Year Public Health Plan (Plan Decenal de Salud Pública) | 2022 | 2022–2031 | This policy integrates national, state, and local actions | Important but not central |
| National | NA | Sport | 2 | National Public Policy for the Development of Sport, Recreation, Physical Activity, and the Use of Leisure Time Towards a Peaceful Territory (Política Pública Nacional para el Desarrollo del Deporte, la Recreación, la Actividad Física y el Aprovechamiento del Tiempo Libre hacia un Territorio de Paz) | 2018 | 2018–2028 | This policy integrates national, state, and local actions | Central | |
| Subnational | Bucaramanga | Health | 3 | No policy | NA | NA | NA | NA | |
| Subnational | Bucaramanga | Sport | 4 | Municipal Development Plan—Bucaramanga City of Opportunities (Plan de Desarrollo Municipal—Bucaramanga Ciudad de Oportunidades) | 2020 | 2023–2023 | This policy adheres to the national health policy (#1) | Secondary | |
| Subnational | Bogotá (capital city) | Sport | 5 | Public Policy on Sports, Recreation, Physical Activity, Parks, Recreational and Sports Scenarios and Equipment (Política Pública del Deporte, la Recreación, la Actividad Física, los Parques, los Escenarios y Equipamientos Recreativos y Deportivos) | 2019 | 2019–2030 | This policy adheres to the national health (#1) and sports (#2) policies | Important but not central | |
| Subnational | Bogotá (capital city) | Health | 6 | Strategic and Operational Plan for the Comprehensive Approach to the Population Exposed or Affected by Chronic Conditions (Plan Estratégico y Operativo para el Abordaje Integral de la Población Expuesta o Afectada por Condiciones Crónicas) | 2020 | 2020–2030 | This policy adheres to the national health policy (#1) | Central | |
| Costa Rica | National | NA | Health | 7 | National Policy of Sport, Recreation and Physical Activity (Política Nacional del Deporte, la Recreación y la Actividad Física) (PONADRAF 2020 − 2030)) | 2020 | 2020–2030 | NA | Central |
| National | NA | Health | 8 | ||||||
| Subnational | San José (capital city) | Health | 9 | ||||||
| Subnational | Nicoya | Education | 10 | ||||||
| Ecuador | National | NA | Health | 11 | Ten-Year Plan for Sport, Physical Education and Recreation (Plan Decenal de la Cultura Física de Ecuador—DEFIRE) | 2018 | 2018–2028 | No | Important but not central |
| National | NA | Sport | 12 | Ten-Year Plan for Sport, Physical Education and Recreation (Plan Decenal del Deporte, Educación Física y Recreación—DEFIRE) | 2018 | 2018–2028 | No | Important but not central | |
| National | NA | Education | 13 | Student Participation Program (Programa de Participación Estudiantil) | 2016 | 2016–2022 | NR | Important but not central | |
| Subnational | Cuenca | Health | 14 | Muévete Ecuador project | 2022 | 2022–2026 | NR | Central | |
| Subnational | Cuenca | Health | 15 | National Sports Reactivation Plan (Plan Nacional de Reactivación del Deporte) | 2018 | 2018–2028 | This policy adheres to the national sports policy (#12) | Central | |
| Subnational | Cuenca | Sport | 16 | Soccer and Athletics Sports Training Schools (Escuelas de formación deportiva de fútbol y atletismo) | 2016 | 2016–2023 | NR | Central | |
| Mexico | National | NA | Health | 17 | Specific Action Program Public Health and Health Promotion Policies (Programa de Acción Específico Políticas de Salud Pública y Promoción de la Salud) | 2022 | 2020–2024 | No | Secondary |
| National | NA | Transport | 18 | No policy | NA | NA | NA | NA | |
| Subnational | Mexico City (capital city) | Transport | 19 | Strategic Mobility Plan (Plan Estratégico de Movilidad) | 2019 | 2019–2024 | No | Important but not central | |
| Subnational | Mexico City (capital city) | Sport | 20 | “Salud en tu vida, Salud para el bienestar” program (Programa Salud en tu vida, Salud para el bienestar) | 2021 | 2021–2024 | No | Central | |
| Subnational | Cuernavaca | Health | 21 | Paseo Palmira project | 2022 | 2022–2024 | No | Central | |
| Subnational | Cuernavaca | Transport | 22 | Agreement to reform the 12th article of the agreement that initiates the certification program for public transportation operators in the state of Morelos (Acuerdo por el que se reforma el artículo décimo segundo del diverso por el que se da inicio al programa de certificación de operadores del transporte público en el estado de Morelos) | 2001 | 2022–2022 | No | Secondary | |
| Subnational | Cuernavaca | Sport | 23 | Social Justice for Morelenses (Justicia Social para los Morelenses) | 2019 | 2019–2024 | No | Central |
Abbreviations: NA, not applicable; NR, not reported.
Policy Operational Structure
Process of National PA Policies
Figure 2A compares national and subnational informants’ perspectives on the subnational level’s involvement in national PA policies. Results show uncoordinated engagement across the policy cycle. During the agenda-setting stage, 39% of subnational informants perceived that their involvement (or that of their peers) in national policies was minimal, while 44% of national informants held the same opinion. In policy formulation, 31% of subnational informants perceived their involvement as low to medium, whereas 44% of national informants had the same perception. Regarding policy adoption, 54% of subnational informants believed they were not heavily involved, while 44% of national informants believed the involvement was moderate. Only 15% of informants at the subnational level and 33% at the national level agreed that the subnational level was heavily involved in the national policy implementation. For evaluation, most subnational and national informants were unaware of subnational involvement in national policies.
—National/subnational-level perspectives of the involvement of the national/subnational level across the 5 policy process stages of physical activity policies: (A) perspectives of the involvement of the subnational level in national physical activity policies and (B) perspectives of the involvement of the national level in subnational physical activity policies. Note. The levels of involvement from darkest to lightest on the color scale are: High, Medium, Low, and I don't know. For the most accurate interpretation of this graph (full range of color) please refer to the electronic version of the manuscript. Key informants were consulted at the subnational and national levels to assess the national and subnational levels’ involvement in the 5 stages of the policy process (ie, agenda setting, policy formulation, adoption, implementation, and evaluation). For example, in the panel (A), the first darkest bar to the left indicates 23% of key informants belonging to the subnational level, reported “high” involvement in the agenda setting stage of national policies. In panel (B), the first darkest bar to the left indicates 15% of key informants belonging to the subnational level, reported the national level having a “high” involvement in the agenda setting stage of subnational policies.
Citation: Journal of Physical Activity and Health 21, 5; 10.1123/jpah.2023-0342
Process of Subnational PA Policies
From a national and subnational level viewpoint, informants assessed the national level’s involvement in the subnational PA policies (see Figure 2B). For agenda setting, 33% of national informants perceived that their involvement (or that of their peers) in subnational policies was low, while 39% of subnational informants perceived that it was moderate. More informants at the national level (22%) than at the subnational level (15%) perceived that the national level was highly involved in formulating subnational policies. In particular, while 23% of subnational informants were unaware of the national level’s involvement during the adoption stage, 44% of national level informants were unaware of their involvement during that stage of subnational policies. In terms of implementation, 31% of informants at the subnational level and 33% of informants at the national level saw that the national sectors were moderately involved in the implementation stage of subnational policies. In addition, while 23% of subnational informants saw the national level as highly involved in the evaluation stage, 56% of national level informants were unaware of their level’s involvement during this stage of subnational policies.
Policy Content
Health centers, clinics and hospitals, care centers, and tourism were the least mentioned settings for implementing PA actions in national policies from Colombia, Ecuador, and Mexico, according to national informants (see Table 4). In addition, in Colombia and Mexico, the prison environment was not mentioned. For Mexico, sectors not included in the national policies were transport, environment, and urban planning, and in Ecuador, only the urban planning sector was not mentioned. In contrast, subnational informants from Colombia and Costa Rica considered that all settings were relevant for subnational PA policies.
Presence of Settings, Audiences, and Additional Sectors in the Physical Activity Policies at the National or Subnational Levels That are Considered Relevant for Implementing Physical Activity Actions
| Colombia | Costa Rica | Ecuador | Mexico | |||||
|---|---|---|---|---|---|---|---|---|
| National level | Subnational level | National level | Subnational level | National level | Subnational level | National level | Subnational level | |
| Settings | ||||||||
| Urban and rural environment | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
| Work environment | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
| Prison environment | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
| Nurseries and infant schools | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
| Elementary and High school | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
| University | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
| Health centers, clinics, and hospitals | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| Care centers | ✓ | ✓ | ✓ | ✓ | ||||
| At home | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
| Sports and leisure | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
| Transportation | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
| Tourism | ✓ | ✓ | ✓ | ✓ | ||||
| Environment | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
| Urban planning | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| City and Neighborhoods | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
| Target audiences | ||||||||
| Preschool children | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
| Children and/or adolescents | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
| Adults | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
| People with disabilities | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
| Seniors | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
| People with chronic diseases | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
| Pregnant women | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
| Additional sectors | ||||||||
| Health | ✓ | ✓ | ✓ | ✓ | ||||
| Sport | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
| Recreation and leisure | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
| Education | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
| Transport | ✓ | ✓ | ✓ | ✓ | ||||
| Environment | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| Urban/rural planning and design | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| Culture | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| Tourism | ✓ | ✓ | ✓ | ✓ | ✓ | |||
| Public finance | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| Work and employment | ✓ | ✓ | ✓ | ✓ | ✓ | |||
| Research | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
At both levels, informants in Colombia, Costa Rica, and Mexico agreed that current PA policies included all audiences (eg, preschool children, children/adolescents, adults). In Ecuador, national and subnational informants agreed with informants from other countries; however, they reported that policy documents did not include pregnant women and people with disabilities. In Colombia and Mexico, subnational informants identified all the listed additional sectors (eg, health, sport, recreation and leisure, education) as important for subnational PA policy implementation.
Policy Implementation
The analysis of policy implementation across both levels revealed different degrees of implementation (see Table 5). In general, 43.5% of informants indicated that the policies were not implemented at all, while 30.4% reported full implementation. In comparison, at the national level, 44.4% reported no implementation, and 22.2% reported full implementation. Furthermore, in capital cities, 60.0% reported full policy implementation, while in secondary cities the majority (55.6%) reported no policy implementation. When examining funding allocated to policy implementation, in general, 56.5% of informants reported allocation, while 34.8% indicated no allocation. In contrast, at the national level, 55.6% reported funding, with 44.4% indicating no allocation. However, in capital cities, all respondents reported funding allocated for policy implementation, while the second city level showed a mixed pattern, with 33.3% indicating funding allocation and 44.4% reporting no allocation.
Degree of Implementation and Funding Allocated to Implementation of Physical Activity Policies (N = 23)
| Total (N = 23) n (%) | National level (N = 9) n (%) | Subnational level (N = 14) | ||
|---|---|---|---|---|
| Capital city (n = 5) n (%) | Second city (n = 9) n (%) | |||
| Policy implementation | ||||
| Not at all implemented | 10 (43.5) | 4 (44.4) | 1 (20.0) | 5 (55.6) |
| Somewhat implemented | 6 (26.1) | 3 (33.3) | 1 (20.0) | 2 (22.2) |
| Fully implemented | 7 (30.4) | 2 (22.2) | 3 (60.0) | 2 (22.2) |
| Funding allocated to policy implementation | ||||
| Yes | 13 (56.5) | 5 (55.6) | 5 (100.0) | 3 (33.3) |
| No | 8 (34.8) | 4 (44.4) | 0 | 4 (44.4) |
| Do not know | 2 (8.7) | 0 | — | 2 (22.2) |
Discussion
To our knowledge, this study is the first to assess the development and implementation processes of PA policies at national and subnational levels in 4 different countries across Latin America. The multisectoral and layered geopolitical architecture of these countries highlighted the complexity of analyzing their policies. The key findings from this study are (1) about a third of the national and subnational policies in all 4 countries were exclusive to PA, and more than half were NCD policies from the health, sport, transport, and education sectors; (2) only one of the 4 countries studied had a coordinated framework with explicit policy links between national and subnational PA documents and moderate involvement of subnational informants in national policies and vice versa; and (3) informants at the national and subnational levels had different views on the importance of PA promotion. More than half of national-level informants recognized it as important but not central, while more than half of subnational-level informants recognized it as central.
Our results show that most PA policies are embedded in NCDs plans/policies. This finding aligned with previous studies that have demonstrated that the development of PA policies has been gradual and uneven among countries worldwide.3,20,21,23 A study conducted by GoPA! in 2020 found that 45.1% of the 164 countries surveyed had a PA policy embedded in their NCD prevention plan, and only 37.8% had a standalone PA policy.3 To counteract the pandemic of physical inactivity, governments, especially in low- and middle-income countries, should emphasize PA on their public health agendas and create sustainable independent policies.6
Our informants reported that almost all settings, audiences, and sectors were relevant for the implementation of PA policies. The Global Action Plan for Physical Activity (GAPPA) 2018–20301 states that these policies must involve the community, education, sport, and recreation, transport, workplace, health care, environment, and urban/rural planning for people to live physically active lives. Also, in line with our results, the Promoting Active Cities Throughout Europe project analyzed local government policies and programs promoting PA across Europe and found that the settings most mentioned were sport and leisure, urban design, environment, tourism, and primary and elementary education.35
We discovered that country-specific policy coordination exists (see Table 3 and Supplementary Material S1 [available online]). In Colombia, despite decentralization, national policies serve as technical references. Given the governance framework in which they are formulated and administered,36 we found a close relationship between the national and subnational policies. The Ministry of Sports and the National Sports System lead the country’s PA policies, coordinating long-term, medium-term, and short-term national and territorial planning.37,38 Similarly, the National Intersectoral Commission, comprised of the Health, Education, Culture, and Sport sectors, promotes intersectoral actions that combine PA policies within other policies in various sectors.39 Although informants in Colombia stated that the policies referred were related, their sustainability depends on overcoming barriers like lack of resources, delays in planning, hiring, and implementation due to government changes at different levels, and a lack of qualified staff.
In Costa Rica, PA, sport, and leisure are covered by a national public policy (see Table 3). The local administration in each canton (see Supplementary Material S1 [available online]) must implement the action plan as designed, but each local government has a certain autonomy established in the Municipal Code.40,41 Each agency (Costa Rican Institute of Sports and Recreation [ICODER] and organizations affiliated with the Costa Rican Network of Physical Activity for Health [RECAFIS]) has its own function within the larger national framework. However, the policy is still in its infancy, having been introduced only in 2020, and faced the COVID-19 pandemic’s restrictions which inevitably limited its effectiveness. The sustainability and implementation of this policy will depend on its agencies fulfilling their duties and allocation of resources.
No apparent links exist between the policies mentioned by informants in Ecuador since there are no official supporting documents at either national or subnational levels (see Table 3). The only written plan identified was the National Sports Reactivation Plan, which follows the national Ten-Year Plan for Sport, Physical Education, and Recreation policy, because the former is a plan to restart PA practice and high-performance sports during the COVID-19 pandemic, and the latter is the legal framework that any plan in the field must follow according to the decentralization of the country.42,43 However, implementing these referred policies has been hindered by the changes in administration, the COVID-19 pandemic, conflicts of interest, and lack of resources.
Subnational initiatives have been undertaken in Mexico despite lacking a comprehensive national plan for PA (see Table 3). Nevertheless, the policies referred by informants do not explicitly state how they are related or contribute directly or indirectly to the particular goals of the national health program since they are typically not coordinated.44 Implementing effective plans and policies will require an integral and multisectoral promotion of PA, avoidance of conflicts of interest with the food industry, appropriate funding allocated, and a framework aligned with the GAPPA.1,44
The central or federal government’s responsibilities are unclear to subnational governments. A previous analysis found 624,166 municipal entities, 11,965 intermediate governments, and 1769 state and regional governments in 122 countries.15 This highlights that national policies need subnational contextualization with the involvement of policymakers at multiple government levels and sectors.2 However, national and subnational policymakers reported low-to-little involvement in the other level’s PA policy processes across the 5 policy process stages (see Figure 2). This is consistent with past results that recognize that multisectoral collaboration is needed but is uncommon and unfortunately a lack of essential partnerships for success characterizes policymaking around PA.2,17
Implementation of PA policies continues to be a challenge for different sectors.21 National health, education, and sport programs are poorly coordinated, but subnational-level initiatives from other sectors (transportation and urban planning) whose primary purpose is not usually encouraging PA have contributed to raising PA levels.44 A previous study on 27 European PA programs found limited intersectoral cooperation and subnational player engagement in policy creation.16 In the policymaking process, there are different agendas and with every new administration, priorities change making it difficult to maintain any momentum on PA promotion efforts achieved previously. Consequently, there is a need to increase the interplay between national and subnational sectors involved in implementing PA policies.
Strengths and Limitations
The strengths of this study are (1) the support of GoPA! and its extensive network facilitating the contact with government key informants and leading to successful data collection, (2) the INTEGRATE-PA-Pol tool’s22 availability in both Spanish and English that facilitated its application, and (3) a high response rate enabled a comparison of the PA policy cycle and interaction across governmental levels in Latin America. Data collection limitations that must be considered include (1) only the stated PA policies currently being implemented were analyzed. It is possible that other PA policies were in place but were not reported by the informants; (2) the questionnaires did not inquire why respondents rated the level PA policy implementation as they did. Further investigation might shed light on the ways in which different contextual factors and interactions between policy players shape responses; (3) the use of snowball/referral sampling cannot ensure that all potentially important informants were included; and (4) the noncapital cities were selected by convenience and therefore may not be representative of all cities in the country. Instrument applicability challenges were the unique territorial divisions and differences in the sectors at national and subnational levels in each country that required clarifications between the research team and the GoPA! Country Contacts.
It is critical to recognize these strengths and challenges in order to implement the INTEGRATE-PA-Pol tool22 and enable a comprehensive exploration of PA policy development and implementation beyond Latin America and in low- to middle-income countries where research of PA policy is limited.
Conclusions
We were able to successfully determine the interaction and coordination that exists between different levels of government in the PA policy cycle. Based on the preliminary findings, there is an opportunity for improvement since the articulation between national and subnational levels is suboptimal. This study proved that it is possible to collect data on national and subnational PA policies in 4 countries across Latin America and provides a valuable tool with the potential to contribute substantially to the knowledge and understanding of the process of developing and implementing PA policies. This research will inform the new policy implementation indicator in GoPA! Country Cards to better understand these processes globally and regionally.
Acknowledgments
The authors thank all informants for sharing their perspectives on national and subnational PA policies. We also thank Samuel Escandón (Universidad de Cuenca, Ecuador), Gisselle Soto (Universidad del Azuay, Ecuador), and Ana Lilia Espinosa De Los Monteros García (National Institute of Public Health of Mexico, Cuernavaca, Mexico) for their contributions in data collection. This research was funded by the Fondo de Apoyo a Profesores Asistentes—FAPA at Universidad de los Andes, Colombia; University of California San Diego, USA; and Universidade Federal de Pelotas, Brazil. Resendiz’s (PhDc) work was in part supported by a Health Promotion and Disease Prevention Research Centers supported by Cooperative Agreement Number U48DP006395 from the Centers for Disease Control and Prevention. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Author Contributions: Conceptualizing and coordinating the study: Mejía Grueso, Pratt, Resendiz, Salvo, Ramírez Varela. Data collection: Mejía Grueso, Resendiz, Salvo, Ruiz Gómez, Leandro Gómez, Revuelta-Sánchez, Araya Vargas, Ochoa-Avilés, Pérez Tasigchana, Jáuregui, Ramírez Varela. Data analysis and drafting the first version of the manuscript: Mejía Grueso, Resendiz, Ramírez Varela. Providing feedback on the first version of the manuscript: Pratt, Resendiz, Salvo, Niño Cruz, Ruiz Gómez, Leandro Gómez, Revuelta-Sánchez, Araya Vargas, Ochoa-Avilés, Pérez Tasigchana, Jáuregui, Hallal. Revising and approving the final version of the manuscript: All authors.
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