In this international study conducted in 76 countries, we found that most of the included countries have formal written PA policies, guidelines for PA, health surveillance or monitoring systems that include measures of PA, and quantifiable national targets for PA. However, the levels of comprehensiveness, implementation and effectiveness of PA policies were generally found to be low-to-moderate. Compared with PA policies, national SB policies were generally less available and comprehensive. They were also less implemented and effective. PA and SB policies were generally more developed in high-income countries and countries of European and Western-Pacific regions.
Availability of PA and SB policies
Formal written PA and SB policies
We found that formal written PA policies are available in most of the included countries, which is consistent with findings of previous studies [27, 28]. This is significant progress from the mid 2000s, when only around 29% of countries had PA policies [27]. However, our findings showed significant differences in the availability of national PA policies between country groups by income level and by world regions. The prevalence of insufficient physical activity is higher in high-income countries than in middle-income and low-income countries [29], which may partly explain why the governments in high-income countries are more likely to prioritise investing in the development of PA policies. Furthermore, in many low- and middle-income countries there is still a lack of country and context specific research on PA and health [30], which could be the reason for lower interest of policymakers to support the promotion of PA.
Low availability of formal written PA policies and PA guidelines may be especially problematic for the Eastern Mediterranean region. In addition to a high prevalence of noncommunicable diseases [31], this region has one of the highest physical inactivity and obesity rates in the world [32]. The call to focus more on developing national PA policies and implementation plans in the Eastern Mediterranean region from several years ago [33], is still justified.
The availability of SB policies was generally lower than the availability of PA policies. This finding is not surprising because public awareness of the potential adverse health outcomes of SB started to be systematically addressed no more than 20 years ago [6, 21]. Most evidence on SB policies and other determinants of SB comes from research conducted in high-income countries [6, 34]. Due to differences in socio-cultural, political, environmental, and legal factors, there is a need for context-specific research on SB policies [34]. More research on SB and associated policies is warranted, because such research may facilitate the development of national SB policies.
PA and SB guidelines
Availability of national PA guidelines is a good indicator of national PA and SB policy, as it shows the government’s intention to support the promotion of more PA and less SB. More effort needs to be put in the development of national SB guidelines, as they were less represented than PA guidelines. The low availability of SB guidelines might be because there is still an ongoing discussion within the research community on whether there is sufficient epidemiological evidence on the dose-response relationship between SB and health outcomes [35, 36]. Furthermore, we found that the difference between high-income and low- and lower-middle-income countries is particularly large in the availability of PA and SB guidelines. The fact that a large majority of low- and lower-middle-income countries do not have national PA and SB guidelines is concerning from a public health perspective. Greater investment is needed in the development or adoption of PA and SB guidelines in low- and lower-middle-income countries, to support their promotion of more PA and less SB in the population.
Most of the included countries have specific PA guidelines for early years, children and young people, adults, and older adults, in accordance with the target groups in the WHO PA recommendations [37, 38]. We found that national guidelines for other, specific target groups were much less represented. The guiding principle for the implementation of the Global Action Plan on Physical Activity 2018–2030 is proportional universality, which states that greatest efforts should be directed towards target populations that are the least active [17]. Countries should consider adopting the proportional universality principle in the development and implementation of their national PA guidelines. In accordance with this principle, specific PA and SB guidelines should be developed for pregnant women, people with disabilities, and people with chronic disease, as these population groups tend to be less active and more sedentary than the rest of the population [39,40,41]. These will likely feature in the updated WHO guidelines, which might facilitate their adoption in countries [42]. It should be acknowledged that the development of specific recommendations for people with disabilities and chronic diseases may be challenging, due to a large variety of different disabilities and diseases and the fact that the guidelines may need to be disability/disease-specific. The research base supporting the development of specific recommendations for people with disabilities and chronic diseases is also less well developed.
National targets for PA and SB
Health policy experts agree that for successful national PA and SB policies it is essential to set quantifiable, comparable national targets [22, 43,44,45]. However, we found that such targets for PA are still not available in nearly half of countries, while only a few countries have such targets for SB. The WHO’s “global” target of “a 15% relative reduction in the global prevalence of physical inactivity in adults and in adolescents by 2030” can only be achieved through the joint effort of all countries contributing to this common goal [17]. This target could be used as a basis for setting a national target for PA in a country that still does not have one, but it should be adapted to the country-specific context. Setting quantifiable targets for SB may be more challenging, because evidence on prevalence of SB and its trends is less developed.
National PA and SB surveillance/monitoring
Health surveillance and monitoring have a key role in assessing the progress towards meeting PA and SB targets [46, 47]. There are still a large number of countries that do not have PA surveillance, particularly in the Eastern Mediterranean region. We also found that national surveillance of SB is less common than PA surveillance. This suggests that many national governments are still not committed to systematically tracking PA and SB in the population, which means that they may not be able to assess their progress in relation to the WHO targets for 2030.
Previous studies have suggested that comprehensive PA and SB surveillance systems are needed to provide a good evidence base for public health interventions and strategies [46, 47]. Our study provided data only on availability of national PA and SB surveillance. Future studies should explore the comprehensiveness of PA and SB surveillance systems, and how they conform to the principles of optimal PA and SB surveillance [47].
Ministries/departments involved in the promotion of more PA and less SB
An approach that integrates policies across settings and sectors is crucial for successful PA promotion at the national level [21, 44, 48,49,50,51]. We found that in most of the included countries ministries/departments in several sectors are, at least notionally, involved in the promotion of more PA and less SB, which suggests that, in this regard, national approaches to PA and SB policy are heading in the right direction. A PA policy audit conducted in several European countries suggested that the sport, health, and education sectors were key drivers of PA policy, and that more opportunities for PA promotion should be created in other sectors [14]. In addition to the ministries/departments of sport, health, and education, in most of the included countries we also found that ministries/departments of recreation and leisure, research, transport, and urban/rural planning and design are engaged in the promotion of more PA and less SB. Despite these encouraging findings, facilitating engagement of ministries/departments across different sectors in PA promotion remains an important task for national governments. There is still ample space for improvement, particularly in the tourism, culture, environment, work and employment, and public finance sectors. Ideally, whole-of-system [17] and structural approaches [52] would be applied, to engage all relevant sectors and utilise knowledge from public health and social sciences. As outlined in the Global Action Plan on Physical Activity 2018–2030, a whole-of-system approach may be necessary to enable adequate policy investments in PA [17].
Comprehensiveness of PA and SB policies
Comprehensiveness is often regarded as a key determinant of successful policies on PA [49, 51, 53, 54]. Our findings suggest that in most of the included countries PA and SB policies are still not sufficiently comprehensive.
In 2013, a review of PA-related policies advocated for an urgent response to the noncommunicable disease burden in low- and middle-income countries by developing comprehensive policies to increase PA [55]. The results of our study show that the level of comprehensiveness of PA policies is higher in countries with higher income level. In our sample, the level of comprehensiveness of PA policies was the lowest in the African and Eastern Mediterranean regions. It may be challenging to develop all necessary components of PA and SB policy within the available budget, particularly in low- and lower-middle-income countries, where government’s spending on the prevention of non-communicable diseases is generally low, and where the prevention of infectious diseases is a competing priority [56, 57]. Limited funding should therefore be carefully distributed, to cover all the essential components of PA and SB policy. Low- and lower-middle-income countries and countries in the African and Eastern Mediterranean regions might benefit from greater support by international experts and organisations in the process of developing and refining their national PA and SB policies. Another option for some countries would be to consider implementing the WHO Global Action Plan on Physical Activity 2018–2030 [17] and adapting their current PA policies accordingly. Governments, non-governmental organisations, academia, and other stakeholders involved in PA promotion are invited to align their efforts towards achieving the targets outlined in the plan [17].
Implementation of PA and SB policies
A recent study found that most countries implemented less than a half of the noncommunicable disease policies recommended by the WHO [58]. The study also found that the number of countries that adopted PA policies is relatively large, but that it dropped between 2015 and 2017. We found that in most of the included countries half or more of the statements from key national PA and SB policies have not been implemented. Policies can be effective only if they are implemented; hence national governments should invest in mechanisms that would ensure better implementation of their PA and SB policies.
Several previous studies from high-income countries reported a lack of: (i) PA policy implementation; (ii) monitoring/evaluation of policy implementation; and (iii) allocated resources for PA policy implementation [25, 44, 49, 59]. From our data, it seems that the situation in low- and lower-middle-income countries is even more challenging, probably because they have fewer available resources for implementation of PA and SB policies. Highly complex policy designs without clear, specific, feasible, timely, and budgeted, and trackable action/implementation plans may be a recipe for failure of policy implementation [60, 61]. Therefore, national governments should rely on evidence from implementation science and aim to establish more efficient systems for implementation of PA and SB policies. National governments should also invest in rigorous evaluation of different types of interventions, sharing lessons learnt, and scaling-up the successful ones [62]. For some national governments, especially in low and lower-middle-income countries, PA promotion may not be a priority at the national level, so developing and piloting smaller-scale interventions at the local level could be a way to start building context-specific evidence.
Effectiveness of PA and SB policies
Effective PA and SB policies are necessary to increase PA and reduce SB in the population. Previous studies reported a lack of evidence on the effectiveness of PA policy [25, 63]. Our findings indicate that the effectiveness of national PA and SB policies in most of the included countries is low to moderate. Timely modification of PA and SB policies is of utmost importance, if they prove to be ineffective. Although this may be a challenging task, countries should invest in establishing efficient and sustainable systems to evaluate national PA and SB policies, and use the gathered data to continuously improve the effectiveness of the policies.
Strengths and limitations of the study
Strengths of this study include: (i) a large sample of countries from all world regions; (ii) separate analyses of PA and SB policies; and (iii) analyses of availability, comprehensiveness, implementation, and effectiveness of the policies.
This study was also subject to some limitations. First, not all the elements of a comprehensive analysis of PA and SB policy could be asked about, because we did not want to overburden our Country Contacts. For the same reason, we could not collect detailed data on all of the analysed policy elements. Second, the way policies are designed and implemented may vary depending on the political system, culture, and institutional settings in a given country [64]. Despite detailed explanations that we provided in our survey, it might be that some questions were not equally applicable to all country contexts. Third, the data were provided by GoPA! Country Contacts. It may be that some of them did not have access to all relevant data on PA and SB policies in their countries. Fourth, not all invited Country Contacts responded to the survey, which may have led to selection bias and reduced generalisability of the results. Finally, in the African and South-East Asian regions we had relatively small sample sizes, compared with other regions. This was mainly due to a lack of internationally visible PA and public health experts in some countries who we could recruit as Country Contacts.
