Global Matrix 4.0 on Physical Activity for Children and Adolescents: Project Evolution, Process Evaluation, and Future Recommendations

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Iryna Demchenko Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
Department of Health Sciences, Carleton University, Ottawa, ON, Canada
Active Healthy Kids Global Alliance, Ottawa, ON, Canada

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Salomé Aubert Active Healthy Kids Global Alliance, Ottawa, ON, Canada

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Mark S. Tremblay Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
Department of Health Sciences, Carleton University, Ottawa, ON, Canada
Active Healthy Kids Global Alliance, Ottawa, ON, Canada
Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada

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Background: The Global Matrix initiative provides unique insights into child and adolescent physical activity (PA) worldwide, yet requires substantial human efforts and financial support. Purpose: This study aimed to evaluate the process and outcomes of the latest edition of the initiative, the Global Matrix 4.0, reflect on its evolution from earlier editions, and provide recommendations for future Global Matrices. Methods: The evaluation followed a predetermined plan, which included collecting and analyzing qualitative and quantitative data from 3 online surveys to participants and online user activity metrics from MailChimp reports and Google Analytics. Results: Global Matrix 4.0 participants (57 teams, 682 experts) assessed the PA status in their country/jurisdiction on at least 10 PA indicators and submitted 570 grades for global comparisons. Surveys were completed by 97% to 100% of targeted respondents and demonstrated predominantly high satisfaction rates (>80%) with participation, outputs, and project management. Lack of funding and inadequate national PA data availability were the commonly reported concerns. Suggestions for improvement included amending indicators’ benchmarks and expanding the scope of the initiative to early years, underrepresented populations, and additional indicators. Conclusions: This evaluation process revealed the positive experience of Global Matrix 4.0 participants and the successful delivery of expected outcomes. Reviewing the core set of indicators and benchmarks, expanding the initiative’s scope, and fundraising efforts are recommended to further optimize the use of resources and maximize impact.

The Global Matrix on physical activity (PA) for children and adolescents is a large-scale international initiative offering unique insights into variations in PA levels and key sources influencing PA in pediatric populations around the world.14 This initiative involves the harmonized development of country-specific PA Report Cards by multidisciplinary teams of experts from numerous countries, with subsequent compilation and comparison of findings at the global level. A PA Report Card is a public-facing document that provides a comprehensive summary and evidence-informed assessment of child and adolescent PA across a series of indicators.5 The assessment is based on the synthesis and examination of the best available national-level data against harmonized indicator benchmarks using an academic letter grade approach.5 The best available national-level data implies the highest quality evidence from various sources accessible in the country (eg, peer-reviewed research, surveillance programs, government policies, unpublished literature), taking into account the relevance, accuracy, representativeness, validity, reliability, and timeliness of data. The common PA indicators include behavioral indicators (Overall PA, Organized Sport and PA, Active Play, Active Transportation, and Sedentary Behavior); individual characteristics (Physical Fitness); and sources of influence on child and adolescent movement behaviors (Family and Peers, School, Community and Environment, and Government).4

The Global Matrix initiative is run under the leadership of the Active Healthy Kids Global Alliance (AHKGA), an incorporated not-for-profit organization composed of a globally representative network of researchers, health professionals, and stakeholders, with headquarters in Ottawa, Canada.6 Since 2014, there have been 4 consecutive editions of the initiative: the Global Matrix 1.0 (2014),1,7 2.0 (2016),2 3.0 (2018),3 and 4.0 (2022),4 with each edition expanding the representation of countries and demonstrating a growing positive impact across multiple sectors nationally and internationally.8,9 The growth of the initiative, however, is a driving factor for the increasing demand for human and financial resources that the AHKGA and participating Report Card teams need to invest in coordination and participation in the Global Matrix. Thus, it is of utmost importance to determine whether the Global Matrix activities have been implemented effectively and efficiently and resulted in the intended outputs. After the release of the Global Matrix 3.0, Aubert et al10 conducted a comprehensive evaluation of the process and outcomes of the third edition of the Global Matrix that allowed the authors to identify several issues and provide recommendations for improvement of future Global Matrices. These evaluations were taken into consideration by the AHKGA for planning and coordination of the subsequent iteration of the initiative, the Global Matrix 4.0, which was released on October 24, 2022, at the International Society for Physical Activity and Health Congress in Abu Dhabi, United Arab Emirates and featured data from 57 countries/jurisdictions (hereafter referred to as countries for simplicity). However, despite all the upgrades made to the Global Matrix over the last decade, the initiative continues to face some challenges and limitations, potentially hindering it from reaching its full potential. Reflecting on past experiences helps identify effective and ineffective components thereby guiding future planning and goal setting. Therefore, there is currently a need for evaluation of the process and outcomes of the Global Matrix 4.0 in order to strengthen the next editions and further optimize the use of resources for achieving the best possible outcomes. This paper aimed to evaluate the process of the Global Matrix 4.0, to reflect on its evolution from past experiences (Global Matrix 1.0–3.0), and to provide recommendations for future Global Matrices.

Methods

Global Matrix 4.0 Development Process and Coordination

The detailed methodology for the harmonized Report Card development5 and compilation of findings into the Global Matrix 4.04 have been previously published. The project involved close collaboration between the AHKGA leadership team (ie, AHKGA Board of Directors and AHKGA support staff who guided the global harmonization process, compilation, and analysis of information) and Report Card country leaders/co-leaders (ie, local team leaders/co-leaders who oversaw their respective country’s Report Card development; hereafter referred to as Report Card leaders for simplicity). The AHKGA Board of Directors consisted of a globally representative group of 10 voting members: President, Vice-President (and North American Representative), Treasurer (and Webmaster), Secretary (and South American Representative), African Representative, Asian Representative, European Representative (and Partnerships Committee Chair), Oceania Representative (and Publications Committee Chair), Communications Committee Chair, and Fundraising Committee Chair. The Board communicated regularly via email and met at bimonthly 2-hour virtual meetings via Zoom (Zoom Video Communications) using a predetermined agenda, which generally included reports on the Global Matrix 4.0 progress followed by discussions and decision making. With assistance from AHKGA support staff (Global Matrix 4.0 Fellow, Research Coordinator, and Research Student), the Board was responsible for preparing instructional, promotional, and evaluation materials for the Global Matrix 4.0 and communicating them to participants. Report Card leaders (ranging from 1 to 3 individuals per Report Card team) led the development of their country’s Report Card following the recommended timeline (Figure 1) and instructions provided by the AHKGA.

Figure 1
Figure 1

Timeline of the Global Matrix 4.0 development.

Citation: Journal of Physical Activity and Health 2025; 10.1123/jpah.2024-0513

Report Card teams had an opportunity to assist the Board with planning and decision making at different stages of the Global Matrix 4.0 by participating in webinar discussions, completing mandatory evaluation surveys (described in detail in the following sections), and nonmandatory surveys on several topics (eg, themes preference for methodology webinars, planning of the Global Matrix 4.0 launch event, agenda items for postrelease debrief meeting, feedback on subnational Report Cards). At the start of the project, the AHKGA signed a Memorandum of Understanding (MOU) with each country’s Report Card leader(s). The MOU was specifically designed for the fourth edition of the initiative to outline what both parties were expected to implement and comply with throughout the process. AHKGA and Report Card country leaders’ responsibilities for fulfilling the objectives of the Global Matrix 4.0 are summarized in Table 1.

Table 1

Summary of AHKGA and Report Card Leaders’ Responsibilities for Fulfilling the Objectives of the Global Matrix 4.0

Areas of responsibilitiesAHKGA’s responsibilitiesReport Card leaders’ responsibilities
Report Card development processProvide Report Card leaders with documents outlining the methods of the Global Matrix 4.0, resources that may be useful for creating Report Card cover and other documents that can facilitate the development and dissemination of the country’s Report Card

Provide guidance to Report Card leaders and answer questions throughout the development process of the Global Matrix 4.0

Follow up with Report Card leaders when deadlines are not met to ensure that relevant tasks are completed on time
Form a working group, comprised of individuals from multiple relevant sectors and national in representation, to develop the country’s Report Card

Ensure the conduct of thorough and unbiased literature reviews by the working group for the collection of the best available evidence

Ensure that the working group conducts thorough and unbiased syntheses of the best available evidence gathered through the literature reviews for each indicator and its respective benchmark(s)

Coordinate the production of an original Report Card cover that can be used to promote the country’s Report Card

Stay on schedule and adhere to timelines and deadlines for the completion of tasks related to the development of the country Report Card
Indicators: definitions, benchmarks, and grading rubricProvide Report Card leaders with information on 10 common PA indicators (Overall PA, Organized Sport, Active Play, Active Transportation, Sedentary Behaviors, Physical Fitness, Family and Peers, School, Community and Environment, and Government), including grading benchmarks for each indicator and a grading rubric, to harmonize the grade assignment processUse the benchmarks and the grading rubric provided by the AHKGA, described in detail elsewhere,4 for evaluating the available data and assigning grades for the common PA indicators

Develop adequate and reasonable benchmarks for any additional indicators (ie, those outside of the 10 common indicators) that their working group decides to include in the country’s Report Card
Grades assignmentAudit the common PA indicators’ grades and rationales submitted by Report Card leadersEnsure assigning accurate grades based on the best available evidence for each indicator and providing detailed rationales justifying the assigned grades
Communication of informationSend regular e-blast messages to Report Card leaders to communicate information regarding Global Matrix 4.0 updates, relevant resources and information, Report Card development timelines, and important deadlinesRead Global Matrix 4.0 e-blasts distributed by the AHKGA
Website presence and accessProvide all countries participating in the Global Matrix 4.0 with a webpage on the AHKGA website (www.activehealthykids.org), where countries be able to report the results of their Report Card, provide links to their Report Card documents and related activities, and showcase their working group

Provide Report Card leaders with individual credentials for accessing password-protected “Member Area” on the AHKGA website populated with Global Matrix-related materialsa
Submit Report Card-related materials and leaders’ information for display on the country webpage on the AHKGA websitea
PublicationsOrganize contracts and processes with journals/publishers to publish the Global Matrix 4.0 findings (in the event that resources are available to pursue publications related to the Global Matrix)Participate in the writing of Report Card articles consistent with the guidance and leadership provided by the AHKGA and ensure adherence to proper scientific writing practices

Contribute to the main Global Matrix 4.0 manuscript if interested in co-authorshipa
Global Matrix 4.0 launch eventWork with the local host partner(s) to organize the Global Matrix 4.0 launch event (in the event that an in-person Global Matrix launch event is feasible)Prepare a poster that describes the results of their country’s Report Card to be presented at the Global Matrix 4.0 launch event, should it occur
EvaluationDevelop at least 3 surveys at various time points throughout the development of the Global Matrix (Baseline, Mid-development, and Final Evaluation)aComplete at least 3 mandatory surveys throughout the development of the Global Matrix (Baseline, Mid-development, and Final Evaluation)
Compliance with lawsComply with all applicable national, regional, and local laws; regulations; government orders; directives; and policies
CostTake responsibility for all own costs of operation and production

Abbreviations: AHKGA, Active Healthy Kids Global Alliance; PA, physical activity.

aResponsibilities that were not stated in the initial version of the Memorandum of Understanding but were communicated via e-blasts and individual/group emails during the development of the process.

Evaluation Plan and Metrics

The evaluation of the process and outcomes of the Global Matrix 4.0 followed a predetermined plan which was developed by the AHKGA leadership team, based off the framework used for the evaluation of the previous edition, the Global Matrix 3.0,10 and adapted for the Global Matrix 4.0. The plan outlined the main milestones, timelines, data collection methods, and data analysis approach and allowed for some flexibility/adjustments during the process (eg, an extension of timelines for registrations due to COVID-19-related challenges). The process indicators included participant engagement, satisfaction levels, and reported successes and challenges during the process. The main outcome indicators comprised the assignment of evidence-based grades to 10 common PA-related indicators by all participating countries, production of public-facing Report Card documents, compilation of country grades and conducting global comparisons, and publication of international and individual country findings in academic peer-reviewed journals. The steps included the collection of feedback from the Global Matrix 4.0 participants, retrieving online user activity metrics, analyzing gathered quantitative and qualitative data, and formulating recommendations for improvement.

Feedback on the Global Matrix development process and outcomes was collected from Report Card teams at different points in time (Figure 1) via 3 mandatory Global Matrix 4.0 Report Card Leader Surveys: Baseline, Mid-development, and Final Evaluation, which were administered online using a cloud-based data management tool Google Forms (Google LLC). The surveys were designed by the AHKGA leadership team specifically for the Global Matrix 4.0 evaluation purposes and covered several areas, including (1) Report Card team composition and teamwork efficiency; (2) registration fees and process; (3) funding; (4) data collection and suitability of the indicators; (5) synthesis/interpretation of information, grade assignment framework, and suitability of benchmarks; (6) timelines; (7) Report Card development and release; (8) Global Matrix 4.0 project management; (9) grades auditing process; (10) manuscript preparation; (11) Global Matrix 4.0 launch experience; (12) Report Card and Global Matrix impact; (13) general satisfaction with participation in the Global Matrix 4.0; and (14) suggestions for the Global Matrix 5.0 planning. A set of questions varied between the surveys (tailored to the project stage) but remained within the main areas listed above. Agreement and satisfaction levels were rated on a 5-point Likert scale anchored with strongly agree/very satisfied and strongly disagree/very dissatisfied. Report Card leaders had an opportunity to provide comments and report issues or successes via open-ended survey questions, via email to the AHKGA leadership team, at AHKGA-led webinars, and at in-person meetings before/after the release of the Global Matrix 4.0. Survey responses were analyzed using descriptive methods, including calculating frequencies and percentages. Insights from open-ended survey responses were summarized using thematic analysis. Overall findings were interpreted narratively and accompanied by tables and figures for better visualization.

A web-based email marketing platform MailChimp (The Rocket Science Group, LLC) was employed to regularly circulate informational e-blasts to Report Card leaders. Tracked MailChimp statistics, such as e-blast reception, open rates, and link clicks, were used as user activity/engagement metrics. Google Analytics (Google, Mountain View) tool was used to analyze the reach of the materials being disseminated through the AHKGA website (www.activehealthykids.org). Information on the frequency and location of visitors during the selected period of time, and data regarding the number of views of specific pages were retrieved from Google Analytics’ audience and content reports. Twitter Analytics (X Corp) tool was used to track social media metrics, such as follower growth, engagement (ie, the number of interactions the Tweet received), and impressions (ie, the number of times users saw the Tweet on Twitter).11 Publications on the Global Matrix 1.0,1 2.0,2 3.0,3,10 4.04,8 and records of discussions from all editions were used to retrieve the specifics of the past experiences and reflect on the evolution of the Global Matrix initiative. Data were collated and analyzed using Microsoft Excel.

Ethics Statement

This work falls within the “Activities Not Requiring Research Ethics Board Review” as described by Article 2.5 of the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans—TCPS 2 (2022),12 as it corresponds to the “quality assurance/quality improvement/program evaluation” category and is used exclusively for assessment, management, and improvement purposes.

Results

Evolution of the Global Matrix From 1.0 to 4.0

The progression in participation across Global Matrix 1.0 to 4.0 is summarized in Figure 2. At the country level, the most prominent expansion occurred in the number of very high Human Development Index (HDI) countries (a 6-fold increase), high HDI countries (a 5.5-fold increase), and the total number of participating countries (a 3.8-fold increase). However, the participation of low and middle HDI countries remained relatively low across Global Matrices (10%–20% of all participants) and demonstrated a 2.3-fold decrease between the third and fourth editions. At the individual level, the most consistent and substantial growth was in the number of Report Card leaders (a 6.3-fold increase) and total number of involved experts (ie, PA researchers and advocates, a 4.6-fold increase).

Figure 2
Figure 2

Global Matrix 1.0 to 4.0 participants at country level (A) and individual level (B). aCountries that participated in at least one of the previous editions—the Global Matrix 1.0 to 3.0. bNumber of experts includes Report Card leaders, team members, trainees, and Active Healthy Kids Global Alliance Board of Directors members and staff. cNumber of trainees includes undergraduate and graduate students, postdoctoral fellows, and other academics/professionals, who were involved or gained experience as part of their training through participation in Report Card and/or Global Matrix development process. HDI indicates Human Development Index.

Citation: Journal of Physical Activity and Health 2025; 10.1123/jpah.2024-0513

Key aspects of the evolution of the Global Matrix initiative from edition 1.0 to 4.0 concerning operational framework and project governance are summarized in Figure 3. An overview of the implementation status of recommendations from Global Matrix 3.0 evaluation is presented (see Table S1 in Supplementary Materials [available online]).

Figure 3
Figure 3

Evolution of operational framework and project governance from Global Matrix 1.0 to 4.0. Abbreviations: AHKGA, Active Healthy Kids Global Alliance; HDI, Human Development Index; IFAPA, International Federation of Adapted Physical Activity; ISPAH, International Society for Physical Activity and Health; MOU, Memorandum of Understanding.

aHDI classifications are available at www.hdr.undp.org/data-center/human-development-index#/indicies/HDI. bWorld Bank Classifications are available at https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups. cMitacs Internship information is available at www.mitacs.ca/about. dAHKGA Fellowship Program is described at www.activehealthykids.org/2022/03/03/ahkga-fellow.

Citation: Journal of Physical Activity and Health 2025; 10.1123/jpah.2024-0513

Process Indicators of the Global Matrix 4.0

During the process of the Global Matrix 4.0, the AHKGA circulated 36 informational e-blasts to Report Card leaders. The e-blasts had an average open rate of 73% (ie, the percentage of email recipients who opened the email out of the total number of successfully delivered emails) and an average click rate of 33% (ie, the percentage of email recipients who clicked a link in the email out of the total number of delivered emails). A full MailChimp report concerning e-blasts is provided in Table S2 in Supplementary Materials (available online). User engagement with AHKGA’s Twitter/X account (x.com/activehealthyk1) included gaining 953 new followers, accumulating 5895 likes, and achieving 593,300 impressions across a total of 277 tweets over the course of the Global Matrix 4.0. The AHKGA website (www.activehealthykids.org) was continuously used throughout the Global Matrix 4.0 with peak usage (11,580 pageviews) at the time of the release event in October 2022. Geographically, the highest number of website users was from North American countries (n = 18,635, 29% of all users). Content-wise, the AHKGA home page accumulated the highest number of pageviews (n = 38,776, 20% of all pageviews). A more detailed summary of the website usage during the Global Matrix 4.0 development is provided in Figure 4.

Figure 4
Figure 4

User engagement with the Active Healthy Kids Global Alliance’s website during the Global Matrix 4.0, data retrieved from Google Analytics. CAPL-2 indicates Canadian Assessment of Physical Literacy–Second Edition.

Citation: Journal of Physical Activity and Health 2025; 10.1123/jpah.2024-0513

The Global Matrix 4.0 Report Card Leader Baseline, Mid-development, and Final Evaluation Surveys were completed by 100%, 97%, and 100% of targeted respondents (ie, 1 Report Card leader per country), respectively. Responses to the surveys are summarized in eAppendix S1 (Baseline Survey), eAppendix S2 (Mid-development Survey), and eAppendix S3 (Final Evaluation Survey) in Supplementary Materials (available online). Figures 5 and 6 present selected items from the surveys, covering the assessment of AHKGA’s project management and the Report Card teams’ performance. The most positive feedback was provided on items related to AHKGA’s instructions, communications, and audit of grades (Figure 5), as well as the process of evidence synthesis and interpretation by Report Card teams (Figure 6). The items related to the registration fees, the organization of the Report Card poster session at the launch event (Figure 5), and the quality and representativeness of national data sources (Figure 6) received the least enthusiastic evaluations.

Figure 5
Figure 5

Report Card leaders’ assessment of Global Matrix 4.0 project management, presented as total agreement rates with listed statements. Note: Data are from the Global Matrix 4.0 Final Evaluation Survey, completed by Report Card leaders in consultation with teams (1 response per team, n = 57). aResponses from those who attended the Global Matrix 4.0 release event in person (n = 22). MOU indicates Memorandum of Understanding.

Citation: Journal of Physical Activity and Health 2025; 10.1123/jpah.2024-0513

Figure 6
Figure 6

Report Card leaders’ self-assessment of team performance presented as total agreement rates with listed statements. Note: Data are from the Global Matrix 4.0 Mid-Development Survey, completed by Report Card leaders in consultation with teams (1 response per team, n = 58).

Citation: Journal of Physical Activity and Health 2025; 10.1123/jpah.2024-0513

A summary of the main challenges and successes encountered by Report Card teams during their participation in the Global Matrix 4.0 is provided in Table 2.

Table 2

The Most Common Major Challenges and Successes Associated With Report Card Development in the Global Matrix 4.0, as Reported by Report Card Leaders

Challenges
Inadequate data availabilityAccording to survey responses from Report Card leaders (1 response per team),

 • 79% indicated the existence of research gaps that affected their ability to assign gradesb

 • 48% reported not having a systematic surveillance system in the countryb

 • 35% conducted their own primary data collection for the Report Cardb

 • 14% did not have data sources of good quality in their countryb

 • 14% did not have nationally representative data in their countryb

Report Card leaders reported concerns about the insufficiency of data (eg, limited sample size, underrepresentation of certain groups, outdated data), difficulties obtaining access to data from government-owned sources, and alignment of available data with Global Matrix benchmarksc
Insufficient fundingAccording to survey responses from Report Card leaders (1 response per team),

 • 46% did not have sufficient funds for Report Card developmentc

 • 54% of teams submitted various applications for funding to support the development of their Report Card, its publication, and/or travel to present findingsc

Of those who applied for funding (n = 31),

 • 74% (n = 23) were successful, either fully (48%, n = 15) or partially (26%, n = 8)c

 • The amount of received funding ranged from around 300 USD to 65,000 USD (for Report Card work)/195,000 USD (for 3.5 y of overall group work, including Report Card preparation)c

 • Sources of funding: university/internal institutional funding (n = 6), health insurance company via direct sponsorship (n = 1) or facilitated by AHKGA (n = 5), government agency/ministry (n = 3), research grant (n = 3), charitable organization (n = 1), and combination of sources (eg, university funding and/or research grant and/or biotechnology company sponsorship; n = 4)c
Challenging grade assignment processReport Card leaders experienced difficulties with using recommended definitions and benchmarks (eg, imprecise definitions, poor alignment of available data in the country with recommended benchmarks)

 • Highest dissatisfaction rates with definitions were for Physical Fitness (18%) and Active Play (14%) indicatorsc

 • Highest dissatisfaction rates with benchmarks were for Active Play (26%) and Physical Fitness (26%) indicatorsc
COVID-19 disruptionsThe COVID-19 pandemic caused disruptions in the Report Card development process, including:

 • Canceled or delayed primary data collection due to quarantine measuresb

 • Team members’ absenteeism due to personal/family sickness and/or prioritization of COVID-related work dutiesb

 • Delays in receiving information from governments and non-government institutionsb

 • Negative impact on Global Matrix 4.0 registration process (17%)a
Limited ability to attend the Global Matrix 4.0 launchReport Card teams experienced challenges in sending representatives to the Global Matrix 4.0 launch event, held in conjunction with the ISPAH Congress 2022 in Abu-Dhabi, United Arab Emirates

 • 39% of Report Card teams had in-person representation at the Global Matrix 4.0 launch eventc

 • Limiting factors included high costs (both registration fees for the ISPAH conference and travel costs), specifics of the event location, COVID-19 pandemic-related travel restrictions and a combination of several factorsc
Successes
Effective teamwork and national collaborationsAccording to survey responses from Report Card leaders (1 response per team),

 • 85% reported effective and efficient functioning of their Report Card teamb

 • 78% felt that their Report Card team was the right size,b with the most common size being between 6 to 20 people • 81% felt that their Report Card team had the right composition of peopleb

 • Multisector representation on the team included experts from the research sector (represented in 93% of teams), education (in 90%), health (in 73%), sport (in 65%), and government (in 58%)
Extension of international networkingParticipants reported establishing extensive connections with international experts, leading to facilitating the exchange of knowledge, best practices, and involvement in other collaborative projects. Global network map of the countries and Report Card leaders, researchers, and advocates participating in the Global Matrix 4.0 is available elsewhere8
Valuable scientific contributionsAccording to survey responses from Report Card leaders (1 response per team),

 • 90% felt that the Global Matrix initiative contributes to an increase in scientific knowledgec

 • 86% published or were in the process of preparation/publishing (at the time of the survey) peer-reviewed manuscripts on their Report Cardc

 • 86% reported that their participation in Global Matrix 4.0 improved their ability to keep up with research in the field, identify research gaps, and surveillance needs
Notable impact beyond academicsAccording to survey responses from Report Card leaders (1 response per team),

 • 90% expected their Report Card to have a positive influence on “powering the movement to get kids moving” in their country through:

  ○ increased public awareness (79%)c

  ○ improved capacity for advocacy (69%)c

  ○ forming partnerships (65%)c

  ○ improved communications and public relations (57%)c

  ○ policy/strategy development (43%)c

Examples of the impact across multiple sectors (eg, informing decision making, capacity building, social engagement) are available elsewhere8
Expansion of outreach effortsIn addition to being represented on the AHKGA website (ie, having a country-specific Report Card page),

 • 53% of teams created/maintained their own Report Card dedicated websitec

 • 37% of teams created/maintained Report Card social media account(s)

 • 39% of teams reported media coverage for Report Card and/or Global Matrix 4.0, adding to a total of > 1200 media hits (stories) globally for the Global Matrix 4.0

Abbreviations: AHKGA, Active Healthy Kids Global Alliance; ISPAH, International Society for Physical Activity and Health.

aBaseline Survey, bMid-development Survey, cFinal Evaluation Survey; a more detailed summary of survey responses is available in (see eAppendices S1–S3 in Supplementary Materials [available online]).

In the Global Matrix 4.0, the AHKGA allowed 3 autonomous regions (Basque Country, Extremadura, and the Region of Murcia) from Spain to participate and develop region-specific Report Cards13,14 along with the national effort.4 This approach was piloted for the first time in the Global Matrix history, and AHKGA Board of Directors members and Report Card leaders from involved regions and the national team were invited to provide their feedback via an additional survey, titled “Global Matrix 4.0: Regional Report Cards” after the Global Matrix 4.0 completion. According to the survey responses (n = 16), participation of these regions was regarded as beneficial to the Global Matrix 4.0 (63%), to Spain’s national Report Card (75%), and to the regions they represent (81%). Overall, according to the Final Evaluation Survey responses (n = 57), leaders from 91% of Report Card teams were “satisfied” or “very satisfied” with participation in the Global Matrix 4.0, finding it personally (88%) and professionally (86%) rewarding. Additionally, 56 out of 57 Report Card leaders indicated an interest in participating in the next edition, the Global Matrix 5.0. The ideal amount of time between Global Matrices was recommended as 4, 3, and 2 years by 35%, 33%, and 23% of the survey respondents, respectively, and a large majority of all participants supported combining the launch of the Global Matrix 5.0 with an international conference (eg, International Society for Physical Activity and Health Congress).

Outcome Indicators of the Global Matrix 4.0

A total of 570 grades for 10 PA indicators were assigned by 57 Report Card teams and audited by the AHKGA leadership team for adherence to the recommended benchmarks and grading rubric, detailed in Aubert et al.4 According to the Final Evaluation Survey, 77% of respondents were “confident” or “very confident” with the accuracy of grades in their Report Card. It should be noted that 18% (n = 105/570) of grades included in the Global Matrix 4.0 received an incomplete (INC) grade, indicating that there was insufficient or inadequate evidence to inform a letter grade. The Report Card leaders’ satisfaction with benchmarks and definitions varied across indicators, with Active Play and Physical Fitness indicators having the least supportive feedback, as illustrated in Figure 7. Survey participants recommended considering additional PA indicators for inclusion in future Global Matrices, with the most common suggestions being Sleep (n = 16), Obesity (n = 7), and Physical Literacy (n = 3). Additional factors recommended for consideration in future editions of the initiative were the inclusion of PA evidence on children under 5 years of age and mandatory disaggregation of grades by gender, ability level, socioeconomic status, and living area.

Figure 7
Figure 7

Satisfaction of Report Card leaders with the definitions and benchmarks for Global Matrix 4.0 indicators. Note: Data are from the Global Matrix 4.0 Report Card Leader Mid-development Survey, completed by Report Card leaders in consultation with teams (1 response per team, n = 58); the satisfaction rate represents a summary of “satisfied” and “very satisfied” responses; the dissatisfaction rate represents a summary of “dissatisfied” and “very dissatisfied” responses. AP indicates Active Play; AT, Active Transportation; C&E, Community and Environment; F&P, Family and Peers; GOV, Government; OPA,  Overall Physical Activity; PF, Physical Fitness; SB, Sedentary Behavior; SCH, School; SP, Organized Sport and Physical Activity.

Citation: Journal of Physical Activity and Health 2025; 10.1123/jpah.2024-0513

Findings from all 57 participating countries were compiled into the “global matrix” of grades with subsequent international comparisons. Concurrent with the public release of the Global Matrix 4.0, the AHKGA published a series of articles in the Journal of Physical Activity and Health, discussing the methodology and main international findings of the Global Matrix 4.0,4 temporal changes in country grades across Global Matrices 1.0 to 4.0,15 patterns and relationships between economic freedom, climate culpability and Global Matrix 4.0 grades,16 disparities in PA among children and adolescents from different subgroups (eg, sex, age, area of residence, and ability levels) in relation to country HDI, and international policy trend for promoting PA among children and adolescents with disabilities.17,18 Further, currently 60% of participating teams (n = 34/57) published peer-reviewed academic articles, discussing individual country-level results of Report Cards. A total of 54 academic articles related specifically to the findings of the Global Matrix 4.0 and corresponding Report Cards have been published in peer-reviewed journals (www.activehealthykids.org/report-card-related-publications) at the time of this manuscript preparation. Additionally, over 100 academic presentations related to the Global Matrix 4.0 and included Report Cards were delivered at international conferences and national/local scholarly events to date (www.activehealthykids.org/report-card-related-presentations), as reported by members of the AHKGA network. Among all the participating countries, 93% (n = 53/57) prepared and launched their public-facing Report Card documents in public domains, including the AHKGA website (available on country pages, www.activehealthykids.org/Country name, eg www.activehealthykids.org/canada). Of all participants, 84% of Report Card teams were “satisfied” or “very satisfied” with their Report Card. Overall, Report Card leaders from participating countries felt that the Global Matrix initiative is contributing to an increase in scientific knowledge (90%), to “powering the movement to get kids moving” (84%), and provides other benefits to society (91%), such as increased national and international collaboration, capacity building, improved surveillance of PA, and increased public and government awareness about PA crisis among children and adolescents. Specific examples of the overall impact of AHKGA efforts, including accomplishments associated specifically with the Global Matrix 4.0 are available at Tremblay et al.8

Discussion

The project evaluation revealed that 57 countries fulfilled the Global Matrix 4.0 requirements and were generally satisfied with their participation in the Global Matrix 4.0, highlighting effective teamwork, an extension of international networking, and valuable contributions to science as their biggest successes. In comparison to the previous editions, the most substantial advancements were made in country representation, human resources, partnerships, and project management, which collectively contributed to the progressive evolution of the Global Matrix initiative. Inadequate data availability, insufficient funding, and challenging grade assignments emerged as the most notable concerns/challenges. Almost all the recommendations that arose from the Global Matrix 3.0 evaluation10 were implemented (fully or partially) in the Global Matrix 4.0 edition, advancing the overall process effectiveness, and contributing to the successful delivery of the expected outcomes.

Areas of Improvement and Recommendations for Future Global Matrices

To help guide future Global Matrices, the following key areas for improvement have been identified, along with the recommended future directions.

Global Reach and Scope Extension

Although the Global Matrix has shown consistent and substantial growth over the years,8 there remains lots of potential for further expansion. It is recommended that the AHKGA network continue its collective efforts to involve a greater number of participants in the project, with a specific focus on encouraging and supporting representation from low and middle HDI countries. If necessary, the support should include extensive mentoring and potential financial assistance (eg, discounted/waived registration fees, assistance with funding applications). Further, it is suggested to explore the possibility of extending the age range for the Global Matrix to include PA evidence on children under 5 years of age (the “early years”). Presently, there is some uncertainty about the feasibility of this extension due to the limited availability and uniformity of data for this age group across the countries. However, the research in this area is growing19 and international collaborations are emerging (eg, with the “SUNRISE” international surveillance study of movement behaviors in the early years20), which could facilitate advancement in this direction. During the Global Matrix 4.0, the AHKGA established a formal partnership with the International Federation of Adapted PA and endorsed the development of a Para Report Card initiative, which compiled assessments of PA of children and adolescents with disabilities from 14 countries, discussed in detail elsewhere.21 For the Global Matrix 5.0, it is recommended to intensively explore and integrate data on PA behaviors and opportunities for equity-deserving groups, including children and adolescents with disabilities. A global call to collect, report, interpret, and discuss findings in relation to children and adolescents with disabilities in Report Cards has been issued by Tremblay et al.22 The recommended next steps are to harmonize operational definitions and terminology, to review and adjust the grade assignment framework and measures, and to develop plans for global analyses.

Adjustments to the Methodological Framework

Based on the feedback from the Global Matrix 4.0 participants and the AHKGA leadership team, the existing grade assignment framework is generally appropriate and well-functioning. However, several aspects were identified that may need adjustments to improve accuracy, alignment with existing PA data, and comparability between the countries. Regarding common indicators’ definitions and benchmarks, Active Play and Physical Fitness received the least favorable feedback (Figure 7). To get insights into the assessment of Active Play, a comprehensive review of global surveillance and monitoring of active play in the context of Global Matrix data has recently been conducted by Lee et al.23 The authors developed 2 sets of age- and location-specific questionnaire items for measurement of the active play, for potential use in the Global Matrix 5.0. A review of the measurement of the Physical Fitness indicator across Report Cards is also warranted to potentially provide solutions for the improvement of assessment and compatibility of grades across the countries. Further, it is recommended to validate the alternative Overall PA benchmark (ie, ≥60 min of moderate to vigorous PA on at least 4 d a week) against global accelerometry data, as it was originally developed using exclusively the Canadian Health Measures Survey24 data. It would also be beneficial to evaluate the alternative grading method for the Government indicator (ie, using the Health-Enhancing PA Policy Audit Tool, version 2 and corresponding scoring rubric), proposed by the Welsh Report Card team for implementation in the Global Matrix 4.0,25 in comparison with the original approach1 based on Report Card committee consensus. Additionally, it is recommended to further discuss the feasibility of disaggregating grades in all Report Cards by gender and introducing additional indicators to the future Global Matrices (eg, sleep, which is an integral part of the 24-h movement continuum26). Finally, there is a high demand for the development of a universal, globally accepted, culturally adaptable instrument/tool for the assessment of PA behavior to improve global surveillance and harmonization in the Global Matrices.4,10,27 The frequent comment from participants about inadequate data availability could be partially addressed by having a valid and reliable global child and adolescent PA questionnaire, and the development of such an instrument is currently underway.28

Refinements to the Operational Framework

The operational framework of the Global Matrix initiative has demonstrated strong performance over the years, and it continues to evolve and improve (Figure 3). For the future Global Matrices, it is recommended to follow a 4-year cycle and extend each stage timelines (eg, for data collection, data synthesis, audit of grades) to optimize resource use, perform quality work without time pressure, and allow greater flexibility in timelines for countries to better align with their specific national contexts. Based on the preferences of Global Matrix 4.0 participating teams, it is recommended that the Global Matrix 5.0 launch be held in conjunction with another international conference, incorporate a virtual component for the main activities, and include a poster session specifically dedicated to the Global Matrix-related works. Additionally, it is advised to organize events (eg, symposiums, workshops) in between Global Matrix launches to provide more opportunities for data mining, knowledge exchange, and collective planning of future steps. Further, given the positive experience with regional Report Cards13,14 in the Global Matrix 4.0, it is recommended to allow smaller jurisdictions (eg, Region of Murcia) to participate alongside the national teams (eg, Spain) in future Global Matrices, under the condition that grades of the subnational Report Cards are not included in quantitative analyses at the global level to avoid overweighting a particular area. It is also suggested that the AHKGA consider developing a public-facing global Report Card to facilitate knowledge translation in future editions of the Global Matrix. Finally, financial issues remain a limiting factor for both the AHKGA and Report Card teams from different countries. Thus, it is recommended that AHKGA continue active fundraising efforts with the long-term goal of reducing or eliminating registration fees for Global Matrix participation, particularly for low- and middle-income countries. For Report Card teams, it is advised to actively explore a variety of funding opportunities (eg, government grants, nonprofit organizations, philanthropy, corporate, academic scholarships), build regional, national and international collaborations for collective funding applications, and demonstrate the impact and sustainability of the Report Card and the Global Matrix project to increase the likelihood of securing funding.

Strategic Impact

The Global Matrix is recognized as one of the few major international PA surveillance initiatives.27,29 In its current state, the initiative has been influential across multiple sectors (eg, academia, research, education, recreation, health, policy) via advancing knowledge, building capacity, raising awareness, and informing decision making.8,9 By capitalizing on successes and tackling common concerns and challenges, identified through this evaluation process, the Global Matrix is expected to evolve into a more robust, comprehensive, representative, and impactful initiative. Addressing the recommended areas for improvement has the potential to enhance the comparison of PA levels and underlying factors across various contexts (eg, geographic, economic, cultural, equity-deserving groups), leading to new insights and approaches. It is also hoped that ongoing fundraising efforts will lead to securing some funding and/or sponsorship, resulting in lowering or abolishing fees for participating countries. As a result, it would be possible to enhance country representation, introduce more staff to increase the project management capacity, create more training/fellowship opportunities for academic/scientific capacity building, and implement advanced technologies and professional services. Altogether, the upgrade of the Global Matrix scope, methodology, and operational framework can ultimately lead to optimizing the process and increasing the initiative’s contributions to “powering the global movement to get kids moving.”

Strengths and Limitations of Evidence

This evaluation of the Global Matrix 4.0 has several strengths, including strong participant engagement, collection of feedback at multiple points during the process, inclusion of quantitative and qualitative information, and cost-effectiveness of the evaluation procedures. Both the AHKGA leadership team and all participating teams had the opportunity to provide their opinions, concerns, and suggestions in multiple ways (eg, surveys, webinar/meeting discussions, emails, in-person postlaunch meeting), contributing to the collective feedback on the project development and assisting with future planning. Collecting information at different time points during the Global Matrix 4.0 process allowed AHKGA to identify challenges, and preferences, some of which could be promptly addressed. Using user-friendly and free/inexpensive online tools (eg, Google Forms, MailChimp, Zoom) contributed to the cost-effective, smooth, and convenient way to engage the widely spread international audience. The evaluation produced valuable insights with minimal use of monetary resources; however, some limitations of this approach should be considered. Several components of the evaluation were subjective, with a risk for certain bias. For instance, AHKGA’s involvement in planning and directing the project and analyzing feedback can potentially introduce bias (eg, the spectrum of questions, the order of answer options in the surveys, subjective aspects of thematic analyses of survey responses). From the participants’ side, there is potential for social desirability bias, especially among first-time participants, who may hesitate to provide feedback that might be deemed undesirable. Additionally, some participants engaged in evaluations more consistently and extensively (eg, active participation in webinar discussions, numerous comments to open-ended survey questions), which can potentially give more consideration to their feedback compared with those who provided less information. To overcome these limitations, AHKGA strives to cultivate a welcoming environment for all opinions, involves as many participants as possible in the planning process and prioritizes transparency.

Conclusions

The evaluation of the process and outcomes of the Global Matrix 4.0 revealed the successful accomplishment of the main objectives and the positive experience of participating countries. The Global Matrix initiative continues to be a powerful force in attracting interest, contributing to scientific evidence, and provoking change at national and global levels. Expanding the initiative’s reach and scope, strengthening methodological aspects, and ongoing fundraising efforts are recommended to further optimize the use of resources and maximize contributions of the Global Matrix to combating the physical inactivity crisis among children and adolescents around the world.

Acknowledgments

The authors are grateful to the current and former AHKGA Board of Directors members for the direction of the Global Matrix initiative and insights on the evaluation process. We are especially thankful to all Report Card leaders, co-leaders, and Report Card team members for their participation in the project and all evaluation procedures. The authors also appreciate and acknowledge the assistance of Evan Turner with survey development and project administration, and the contributions of Myranda Hawthorne to the audit of grades, survey development, summarizing of survey responses, and project administration. Declaration of Competing Interest: The authors want to disclose that they were members of the AHKGA Board of Directors (Aubert and Tremblay) and AHKGA support staff (Demchenko) during the development of the Global Matrix 4.0. Data Availability Statement: The data that informed this study are available upon reasonable request. Author Contributions: All authors conceived the original idea and designed the study; Tremblay directed the project; all authors contributed to the development of evaluation procedures; Demchenko wrote the initial draft, Aubert and Tremblay revised it critically for important intellectual content; all authors reviewed and approved the final manuscript.

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The evaluation of the process and outcomes of the Global Matrix 4.0 revealed the successful accomplishment of the main objectives of the initiative and generally positive experience of participating countries/jurisdictions.

Reflecting on past experiences helped identify effective components and areas for improvement, thereby guiding future Global Matrices planning and goal-setting.

Expanding the initiative’s reach and scope, strengthening methodological aspects, and continuing fundraising efforts are recommended to optimize the use of resources and maximize the impact.

Supplementary Materials

  • Collapse
  • Expand
  • Figure 1

    Timeline of the Global Matrix 4.0 development.

  • Figure 2

    Global Matrix 1.0 to 4.0 participants at country level (A) and individual level (B). aCountries that participated in at least one of the previous editions—the Global Matrix 1.0 to 3.0. bNumber of experts includes Report Card leaders, team members, trainees, and Active Healthy Kids Global Alliance Board of Directors members and staff. cNumber of trainees includes undergraduate and graduate students, postdoctoral fellows, and other academics/professionals, who were involved or gained experience as part of their training through participation in Report Card and/or Global Matrix development process. HDI indicates Human Development Index.

  • Figure 3

    Evolution of operational framework and project governance from Global Matrix 1.0 to 4.0. Abbreviations: AHKGA, Active Healthy Kids Global Alliance; HDI, Human Development Index; IFAPA, International Federation of Adapted Physical Activity; ISPAH, International Society for Physical Activity and Health; MOU, Memorandum of Understanding.

    aHDI classifications are available at www.hdr.undp.org/data-center/human-development-index#/indicies/HDI. bWorld Bank Classifications are available at https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups. cMitacs Internship information is available at www.mitacs.ca/about. dAHKGA Fellowship Program is described at www.activehealthykids.org/2022/03/03/ahkga-fellow.

  • Figure 4

    User engagement with the Active Healthy Kids Global Alliance’s website during the Global Matrix 4.0, data retrieved from Google Analytics. CAPL-2 indicates Canadian Assessment of Physical Literacy–Second Edition.

  • Figure 5

    Report Card leaders’ assessment of Global Matrix 4.0 project management, presented as total agreement rates with listed statements. Note: Data are from the Global Matrix 4.0 Final Evaluation Survey, completed by Report Card leaders in consultation with teams (1 response per team, n = 57). aResponses from those who attended the Global Matrix 4.0 release event in person (n = 22). MOU indicates Memorandum of Understanding.

  • Figure 6

    Report Card leaders’ self-assessment of team performance presented as total agreement rates with listed statements. Note: Data are from the Global Matrix 4.0 Mid-Development Survey, completed by Report Card leaders in consultation with teams (1 response per team, n = 58).

  • Figure 7

    Satisfaction of Report Card leaders with the definitions and benchmarks for Global Matrix 4.0 indicators. Note: Data are from the Global Matrix 4.0 Report Card Leader Mid-development Survey, completed by Report Card leaders in consultation with teams (1 response per team, n = 58); the satisfaction rate represents a summary of “satisfied” and “very satisfied” responses; the dissatisfaction rate represents a summary of “dissatisfied” and “very dissatisfied” responses. AP indicates Active Play; AT, Active Transportation; C&E, Community and Environment; F&P, Family and Peers; GOV, Government; OPA,  Overall Physical Activity; PF, Physical Fitness; SB, Sedentary Behavior; SCH, School; SP, Organized Sport and Physical Activity.

  • 1.

    Tremblay MS, Gray CE, Akinroye K, et al. Physical activity of children: a global matrix of grades comparing 15 countries. J Phys Act Health. 2014;11(suppl 1):S113S125. doi:

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

    Tremblay MS, Barnes JD, González SA, et al. Global matrix 2.0: report card grades on the physical activity of children and youth comparing 38 countries. J Phys Act Health. 2016;13(suppl 2):S343S366. doi:

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

    Aubert S, Barnes JD, Abdeta C, et al. Global matrix 3.0 physical activity report card grades for children and youth: results and analysis from 49 countries. J Phys Act Health. 2018;15(suppl 2):S251S273. doi:

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

    Aubert S, Barnes JD, Demchenko I, et al. Global matrix 4.0 physical activity report card grades for children and adolescents: results and analyses from 57 countries. J Phys Act Health. 2022;19(11):700728. doi:

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

    Colley RC, Brownrigg M, Tremblay MS. A model of knowledge translation in health: the active healthy kids Canada report card on physical activity for children and youth. Health Promot Pract. 2012;13(3):320330. doi:

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

    About » Active Healthy Kids Global Alliance. 2024. Accessed April 28, 2024. https://www.activehealthykids.org/about/

  • 7.

    Tremblay MS. 2014 global summit on the physical activity of children. J Phys Act Health. 2014;11(suppl 1):182. doi:

  • 8.

    Tremblay MS, Barnes JD, Demchenko I, et al. Active healthy kids global alliance global matrix 4.0—a resource for physical activity researchers. J Phys Act Health. 2022;19(11):693699. doi:

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

    Aubert S, Barnes JD, Forse ML, et al. The international impact of the active healthy kids global alliance physical activity report cards for children and youth. J Phys Act Health. 2019;16(9):679697. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Aubert S, Barnes JD, Tremblay MS. Evaluation of the process and outcomes of the Global Matrix 3.0 of physical activity grades for children and youth. J Exerc Sci Fit. 2020;18(2):8088. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11.

    Twitter Analytics Account Overview for Activehealthyk1. 2023. Accessed June 12, 2023. https://analytics.twitter.com/user/activehealthyk1/home

  • 12.

    Government of Canada IAP on RE. Tri-council policy statement: ethical conduct for research involving humans—TCPS 2 (2022). 2023. Accessed April 28, 2024. https://ethics.gc.ca/eng/policy-politique_tcps2-eptc2_2022.html

    • Search Google Scholar
    • Export Citation
  • 13.

    Mendoza-Muñoz M, Castillo-Paredes A, Muñoz-Bermejo L, et al. A regional report card on physical activity in children and adolescents: the case of Extremadura (Spain) in the Global Matrix 4.0. J Exerc Sci Fit. 2024;22(1):2330. doi:

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

    López-Gil JF, Sainz de Baranda P, González-Gálvez N, et al. Region of Murcia’s 2022 report card on physical activity for children and youth. J Exerc Sci Fit. 2024;22(3):227236. doi:

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

    Reilly JJ, Barnes J, Gonzalez S, et al. Recent secular trends in child and adolescent physical activity and sedentary behavior internationally: analyses of active healthy kids global alliance global matrices 1.0 to 4.0. J Phys Act Health. 2022;19(11):729736. doi:

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

    Lee EY, Abi Nader P, Aubert S, et al. Economic freedom, climate culpability, and physical activity indicators among children and adolescents: report card grades from the global matrix 4.0. J Phys Act Health. 2022;19(11):745757. doi:

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

    Silva DAS, Aubert S, Ng K, et al. Association between physical activity indicators and human development index at a national level: information from global matrix 4.0 physical activity report cards for children and adolescents. J Phys Act Health. 2022;19(11):737744. doi:

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

    Sit C, Aubert S, Carty C, et al. Promoting physical activity among children and adolescents with disabilities: the translation of policy to practice internationally. J Phys Act Health. 2022;19(11):758768. doi:

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

    Carson V, Draper CE, Okely A, Reilly JJ, Tremblay MS. Future directions for movement behavior research in the early years. J Phys Act Health. 2023;21(3):218221. doi:

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

    Okely AD, Reilly JJ, Tremblay MS, et al. Cross-sectional examination of 24-hour movement behaviours among 3- and 4-year-old children in urban and rural settings in low-income, middle-income and high-income countries: the SUNRISE study protocol. BMJ Open. 2021;11(10):e049267. doi:

    • Crossref
    • Search Google Scholar
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