The World Health Organization (WHO) recently published global guidelines on physical activity and sedentary behavior.1,2 These guidelines acknowledge and endorse the many benefits of physical activity to individual health and well-being, including a reduced risk of noncommunicable diseases, as well as improved mental health, sleep, and cognitive function.1,2 In addition, improvements made to population levels of physical activity can contribute to other key international agendas, including the 2030 Agenda for Sustainable Development.3,4
Despite the substantial and wide-ranging benefits of physical activity, 1 out of 4 adults and 4 out of 5 adolescents globally are insufficiently active.5,6 Furthermore, inequities in participation exist by geography, sex, and social gradient.5 While many countries have developed policies to tackle physical inactivity,7 global prevalence has remained relatively static over the past 20 years, emphasizing the need for greater investment and cross-sectoral action.5
In 2018, the WHO published the Global Action Plan on Physical Activity 2018–2030.8 This document set a global target for a 15% reduction in physical inactivity by 2030. This global action plan outlines a wide range of actions across multiple sectors and settings, including schools, health care, transport, urban planning, public education, sport, communities, and workplaces.8 However, advocacy efforts will be required to engage each of these sectors and settings and encourage implementation of the actions outlined in the plan.9
The WHO Guidelines on Physical Activity and Sedentary Behaviour (2020) and the Global Action Plan on Physical Activity 2018–2030 are landmark documents which summarize the evidence and set the global direction for increasing population levels of physical activity. However, neither document was specifically created as an advocacy tool to increase engagement in the physical activity agenda or encourage increased investment and action.
The International Society for Physical Activity and Health (ISPAH) is a leading global organization working to advance research, policy, and practice to promote physical activity. One of ISPAH’s goals is to lead advocacy actions to advance knowledge translation and improve policy and practice. Establishing consensus on ‘what works’ to change physical activity behavior is a cornerstone of successful advocacy, as is having appropriate resources to communicate key messages to a wide range of stakeholders.10,11
In 2010, ISPAH published The Toronto Charter for Physical Activity, which was a call to all countries to make physical activity a priority for all.12 Subsequently ISPAH published Noncommunicable Disease Prevention: Investments that Work for Physical Activity,13 which provided a summary of the evidence on how to get populations more active across multiple sectors and settings. Successive global policy documents, particularly the WHO Global Action Plan on Physical Activity 2018–2030, have largely aligned with the actions recommended in ISPAH’s 2011 Investments That Work document; however, they include an additional key setting—workplaces.
Given the expanding evidence on the effectiveness of interventions used to promote physical activity and the inclusion of workplaces in the WHO Global Action Plan on Physical Activity 2018–2030, it was timely to review and update the 2011 Investments That Work document. The updated 2020 document includes 8 investments.14 In this paper, we briefly introduce each investment area and reflect on how the updated document can be used to develop and support a clear physical activity advocacy strategy.
Methods
The 8 areas included in the updated document were agreed upon via consensus of the ISPAH board and were based on the 2011 Investments That Work document as well as a review of the actions set out in the WHO Global Action Plan on Physical Activity 2018–2030. A lead for each area was appointed, who then conducted a nonsystematic literature review. Collaborations were formed between board members and experts outside of the board to draft each investment. All of the board members that contributed to the document reviewed every investment area. The final content for each of the investments was agreed upon through consensus. The 8 investments are explained below and summarized in Figure 1.
—Eight Investments that Work for Physical Activity.
Citation: Journal of Physical Activity and Health 18, 6; 10.1123/jpah.2021-0112
Eight Investments That Work for Physical Activity
1. ‘Whole-of-School’ Programs
A whole-of-school approach is a multi-component approach committed to promoting physical activity to all members of the school community through supportive policies, environments, and sustainable opportunities. There is growing evidence to support the efficacy of a range of physical activity promotion strategies in schools, including physical education programs that develop confidence, competence, and motivation to be active;15 active classrooms;16,17 after school physical activity opportunities;18 activities during recess/break times;19 and the promotion of active transport to and from school.20
2. Active Transport
Active transportation to and from places is a practical and sustainable way to increase daily physical activity for many people. Eight interventions have been identified that, when combined, have been shown to encourage walking, cycling, and public transport use, while reducing private motor vehicle use. These 8 interventions include improving destination accessibility; ensuring equitable distribution of employment across cities; managing demand by reducing availability and increasing the cost of parking; designing pedestrian-friendly and cycling-friendly infrastructure to support movement networks; achieving optimum levels of residential density; reducing distance to public transport; increasing the diversity of residential areas; and enhancing the desirability of active travel modes.21
3. Active Urban Design
The way urban and suburban environments are built and designed influences many of our conscious and unconscious behavioral choices. Research from cities globally has shown that adults who live in the most activity-friendly neighborhoods engage in at least an hour (up to an hour and a half) more physical activity per week than those living in the least activity-friendly neighborhoods.22 The creation of neighborhoods that locate shops, schools, parks, recreational facilities, jobs, and other services near homes, and provide highly connected street networks that make it easy for people to walk and cycle to destinations, have been shown to increase physical activity while simultaneously providing many additional health and environmental benefits.23
4. Health Care
Health care professionals come into contact with large proportions of the population and are a trusted source of health advice; therefore, they have a key role to play in promoting physical activity to their patients. Evidence indicates that primary care-based interventions that target physical activity alone, or in combination with interventions for other modifiable risk factors such as tobacco use, the harmful use of alcohol, and unhealthy diets, have shown they are effective24–26 and most are also cost-effective.27 There is strong evidence for providing brief advice and counseling, particularly when linked with community opportunities and support.25,28,29
5. Public Education, Including Mass Media
Public education, including mass media, can involve print, audio and electronic media, digital and social media, outdoor billboards and posters, public relations, and point of decision prompts. It can increase knowledge, awareness, and intent to increase physical activity.30,31 National and community-based communication campaigns should follow best practice principles, including positive framing, tailoring and targeting, and the use of theory and formative research.32 Public education should be combined with supportive infrastructure and other opportunities for physical activity, including community-based programs.8,33
6. Sport and Recreation for All
There is increasing evidence of the wide-ranging health, social and economic benefits of sport,34 and for many, playing and engaging in sport holds significant cultural meaning.35 Participation in sport and recreation can be encouraged through the provision of accessible and appropriate places and spaces, including both indoor and outdoor facilities and amenities,36 as well as opportunities through formal and informal clubs and programs.37,38 Mass events that engage whole communities can help to create a social norm for participation in sport and recreation.39,40
7. Workplaces
The workplace is one of the most opportune settings for health promotion, which can benefit employers via reduced absenteeism41 and burnout42 among employees. Policies and programs include designing workplace environments that promote incidental physical activity; supporting active commuting; educational events to inform employees of the benefits of physical activity; encouraging an active working culture (such as walking meetings); providing employees with paid time and/or flexible time for physical activity; and encouraging self-monitoring via wearable devices or mobile phone apps.43,44
8. Community-Wide Programs
Community-wide programs offer more than one approach to tackle physical inactivity in a population as they operate at multiple levels (individual, social network, neighborhood, and society) to impact behavior.45 These programs can use systems-based approaches to create supportive policies, environments, and programs to encourage whole communities to be more physically active. Community-wide programs can include a mix of components identified in the preceding 7 investment areas, with emphasis on multi-component programs and a broad community reach.46 Settings such as community centers, shopping malls, senior care centers, and faith-based settings might be particularly important for an inclusive community-wide approach.
Discussion
It is well documented that physical inactivity is highly variable between countries and world regions; and there are many barriers to physical activity promotion, particularly in low and middle-income countries, which have many competing priorities.47 While ISPAH’s Eight Investments That Work for Physical Activity are supported by evidence of effectiveness and have broad applicability, the feasibility of implementation will likely be context specific. For this reason, countries should begin by implementing the investments that are considered most feasible, based on factors such as political will, leadership, resources, and existing provision.
The Eight Investments That Work document is a “call to action for everyone, everywhere, including professionals, academics, civil society, and decision-makers, to embed physical activity in national and sub-national policies.”14 In order to realize the greatest benefit from these investments, we encourage policymakers to adopt a systems-based approach.48 Such an approach moves away from isolated, individualized interventions to collaborative cross-sector efforts that work in a complementary way to facilitate population levels of physical activity. In financially constrained times, a systems approach also helps to make efficient use of scarce resources.
Implementing a systems-based approach to physical activity promotion requires engagement with a wide range of stakeholders across multiple sectors and acknowledgment of the co-benefits of physical activity. When communicating with stakeholders, it is important to emphasize the benefits of physical activity that are likely to resonate with their current priorities.9,49 A systems-based approach allows stakeholders to identify where they fit within a bigger picture and to understand how their work contributes both to the problem and the solution. Communities also have a key role to play within a systems-based approach; they can mobilize local community assets, foster engagement from local residents, and provide insight into the reality of the problem.
In an effort to support physical activity advocacy, ISPAH has created a range of resources related to the 8 investments described in this paper. First, the Eight Investments That Work for Physical Activity document itself, which summarizes the evidence for each investment, as well as the benefits of adopting a systems-based approach.14 This document is available in the 6 official languages used by the United Nations, as well as a growing number of other languages. The authors have adapted the content of Eight Investments That Work for Physical Activity into an infographic and animation video to increase awareness of the document, distill key information for a wide range of stakeholders and reemphasize the “call to action.”50 An audiobook has been created, along with podcasts on each investment area and the importance of taking a systems-based approach. These resources form part of the ‘advocacy toolkit’ which is available via the ISPAH website (www.ispah.org/resources). These resources provide an entry point to conversations with stakeholders across multiple sectors and settings. It is critical that physical activity researchers, practitioners, and policymakers around the world utilize these resources to raise awareness, encourage greater engagement, and make the case for investment and action.
Conclusions
The physical activity field has advanced significantly in the decade since the Toronto Charter for Physical Activity.12 Through confident articulation and advocacy for the right combination of policies, environments, and opportunities for physical activity, we have seen these reflected in global and national policy documents. Through these policies and interventions, it is possible to create more physical activity-friendly communities and support the global population toward leading more active lifestyles. This will lead to significant gains in physical and mental health as well as other benefits, including more attractive and less polluted environments, more connected communities, improved transport systems, and a stronger economy. Given the impact of COVID-19 on population physical activity levels and mental health, there has never been a more critical time to invest in actions that work to increase population levels of physical activity.
Acknowledgment
All authors declare that they have no conflicts of interest.
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