4. Policy options to increase physical activity
To increase physical activity levels in the population, a wide range of policy options exists. This chapter provides an overview of these policies, drawing on case studies from across the European Union. The chapter covers interventions in schools, workplaces, and in the health care setting, as well as communication and information policies, policies to increase access to sports facilities, and to change the environment to encourage active transport and outdoor activities. It advocates for a comprehensive, well-funded package of policies to get people moving.
Increasing physical activity levels can have considerable health and economic benefits, including an increase in life expectancy, fewer cases of NCDs, and lower health care expenditure.
Despite many countries having stepped up their efforts to promote physical activity, there remain gaps in the policy response. For example, schemes to promote active travel to school or work are only present in 14 and 17 out of 27 EU Member States, respectively.
A wide range of policy options exist to increase population physical activity, which improve population health, as well as reduce health care expenditure, including:
As physical activity is a complex behaviour, a comprehensive package of policies is needed to target all its drivers at the same time, with sufficient and sustained funding and evaluation.
A policy package aimed at increasing physical activity, implemented in 36 countries, would save around EUR 14 billion in health cost by 2050 (equivalent to the total annual health care expenditure of Greece) and return EUR 1.7 for every EUR 1 invested.
Despite the recognised health and well-being benefits of physical activity, many people do not move enough. As shown in Chapter 3, eliminating insufficient physical activity would have a considerable impact on population health: if everyone in the 27 EU Member States would do at least 150 minutes of moderate-intensity activity per week, more than 10 000 premature deaths could be avoided each year, and 11.5 million cases of new NCDs would be prevented over the next three decades. Increasing physical activity would also reduce the burden on countries’ health care expenditure. If the guidelines of 150 minutes of moderate-intensity physical activity per week were met, countries would save 0.6% on average of their health care expenditure – a total of EUR 8 billion per year.
The impact of insufficient physical activity on health care expenditure presented in this report is comparable to previous estimates, albeit at the lower end of the range (Figure 4.1). Since the OECD SPHeP-NCDs model takes into account diseases and health care cost not related to insufficient physical activity (e.g. if people live longer due to increased physical activity levels, they would develop other conditions), the impact estimated by the OECD model is expected to be lower than when using a PAF approach (see also Chapter 3, Box 3.3).
It has to be noted that the benefits of increased physical activity reach far beyond population health and health care expenditure. A healthier population translates into a larger, more productive workforce. The health and economic impact of the current and potential future pandemics may be lessened (Box 4.1). Finally, there are beneficial links between physical activity policies and other important policy areas such as the environment (Box 4.2). Altogether, there is a strong case to invest in policies that increase physical activity levels in the population.
As discussed in Chapter 2, physical activity levels appear to have decreased during the COVID-19 pandemic. Policies to encourage physical activity would not only mitigate this effect, but can have wider impacts on the COVID-19 recovery.
Firstly, physical activity improves the health of the population, making it more resilient against COVID-19 and any potential future outbreaks. Evidence has shown that physical activity provides protective effects against severe COVID-19 outcomes (Sallis et al., 2021[2]), and people without NCDs are less likely to develop severe symptoms or die from COVID-19 (Jordan, Adab and Cheng, 2020[3]). Moreover, regular moderate to vigorous physical activity has been shown to increase the potency of vaccination (Chastin et al., 2021[4]).
Secondly, physical activity can reduce the considerable impact that the pandemic has had on mental health and well-being. Since March 2020, prevalence of anxiety and depression has increased and in some countries it even doubled (OECD, 2021[5]). Physical activity can help to tackle this issue, as it is as effective as cognitive behavioural therapy or antidepressant medication for mild depressive symptoms (WHO, 2019[6]). Moreover, organised sports provide important social connections after a period of social distancing.
Thirdly, the sports and exercise industry was hit hard during the pandemic, as confinement and other containment measures meant long-term closures for many sports facilities, clubs and informal exercise groups. Across the EU Member States, it is estimated that as much as EUR 47 billion has been lost in sports-related GDP (15.3% of total sports-related GDP) due to COVID-19, as well as 844 773 jobs (16.1% of total sports-related employment) (European Union, 2020[7]). Investing in sports and physical activity can therefore contribute to the economic recovery as well as public health.
Climate change and the degradation of the environment are considered some of the major global threats of our age, and many countries have put in place extensive policies to reduce emissions, mitigate the impacts of climate change and restore biodiversity. Fortunately, many environmental policies also have a beneficial impact on physical activity – and vice versa.
Active transport: To reduce emission and energy use, climate change policies have been introduced to encourage cycling, walking and other forms of sustainable, active transport.
Green space: Parks and other green spaces sequester carbon dioxide, help mitigate the urban heat island effect and provide habitat for urban biodiversity, whilst also providing space for people to be active.
Clean air: Air pollution is a major environmental concern, and can impede people from exercising outside. Policies to reduce pollution, such as taxes, can therefore have a dual effect.
In Finland, the government adopted a resolution in 2018 to promote active and sustainable modes of transportation. The resolution highlights both the environmental and public health impact of active transport. A number of programmes support this resolution, which are co-funded by different ministries, including both the ministry of environment and of social affairs and health, and are carried out in partnership with the transport sector and nongovernmental organisations (NGOs). The Smart to School programme, for example, aims to increase active travel to school, improve road safety, strengthen a culture of active transportation and support schools to implement policies that promote these objectives. Similarly, the Smart to Work forum is a nationwide network of governmental, labour and NGOs that promotes active travel as a strategy to increase levels of physical activity among workers and encourage climate friendly choices.
Source: OECD (2017[8]), Healthy People, Healthy Planet, www.oecd.org/health/healthy-people-healthy-planet.htm; Abu-Omar, Gelius and Messing (2020[9]), Physical activity promotion in the age of climate change, 10.12688/F1000RESEARCH.23764.2; (2018[10]), Programme and government resolution to promote walking and cycling, https://www.lvm.fi/en/-/programme-and-government-resolution-to-promote-walking-and-cycling-970101; WHO (2021[11]), 2021 physical activity factsheets for the European Union Member States in the WHO European Region, https://www.euro.who.int/en/health-topics/disease-prevention/physical-activity/data-and-statistics/physical-activity-fact-sheets/2021-physical-activity-factsheets-for-the-european-union-member-states-in-the-who-european-region.
A wide range of policy options exist to increase population physical activity, including regulatory, economic and information policies. Some are setting- or target-group specific – for example interventions in schools, workplaces or in the health care setting. Other policies aim to increase access to sports facilities, or change the environment to encourage active transport and outdoor activities. Communication policies can be used to encourage physical activity and inform people about what to do, when and where (Figure 4.2). The remainder of this chapter discussed the different policy options and presents selected case studies from EU Member States.
Almost all EU Member States monitor physical activity levels in adults and children, and have physical education in schools (Figure 4.3). Moreover, since 2015, there has been a strong increase in the number of countries that have policies to improve access to physical activity for socially disadvantaged groups and older adults, and schemes for physical activity promotion in schools and the workplace.
However, there is still considerable scope to expand the policy response across the Europe. In particular, few countries have implemented programmes to involve sports clubs in health promotion (Sports Clubs for Health, see also Box 4.6), or systematically apply the European guidelines in planning leisure-time infrastructure (IMPALA, see also Box 4.8). Schemes to promote active travel to school or work are only present in 14 and 17 out of 27 EU Member States, respectively. Moreover, while in 2015 all countries reported having a HEPA policy or action plan that specifically targets high needs groups (e.g. young children, older adults people in low socio-economic groups, people with a disability), in 2021 only 20 out of 27 countries had such policies.
Note: Direct comparisons of the data must be made with caution, as the questions in the three surveys were slightly different, new focal points may have collected data differently and different Member States responded to the survey in each round (Greece did not participate in the survey in 2015, and the United Kingdom was no longer a Member State of the EU in 2021).
Source: WHO (2021[11]), 2021 physical activity factsheets for the European Union Member States in the WHO European Region, https://www.euro.who.int/en/health-topics/disease-prevention/physical-activity/data-and-statistics/physical-activity-fact-sheets/2021-physical-activity-factsheets-for-the-european-union-member-states-in-the-who-european-region.
School-based programmes
Schools can play an important role in increasing physical activity, by providing education on the importance of physical activity as well as by offering physical activity opportunities during and after school. Physical education classes have been shown to make students more active in, outside, and beyond school, as well as having a positive effect on students’ social skills and social development (OECD, 2019[12]). It may also improve educational outcomes (Norris et al., 2019[13]) and contribute to healthy lifestyles that last into adulthood (Dohle and Wansink, 2013[14]; Black et al., 2019[15]). In all EU Member States (WHO, 2021[11]), schools are required by law to provide physical education classes.
However, there is considerable variation in how physical education is defined and quantified, how it relates to and encompasses health education, how it is inscribed and regarded within the curriculum, and, importantly, how it is implemented and assessed in schools (OECD, 2019[12]). While all EU Member States reported having physical education classes, only 74% monitored their quality (WHO, 2021[11]).
Besides physical education classes, physical activity can also be encouraged in schools through targeted programmes (Box 4.3). In the EU, programmes to encourage active school breaks have been implemented in 12 countries, active breaks during lessons in 16 countries, after-school physical activity programmes in 21 countries and programmes to encourage active travel to school in 14 countries (WHO, 2021[11]).
Hungary: Mandatory daily physical education classes
The 2012 Public Act on Education introduced daily physical education (PE) classes as of school year 2012/2013 for grades 1, 5 and 9 in a staggered implementation system. This meant that by September 2015, all students in the Hungarian education system had compulsory PE classes every day. Since September 2013, the new National Core Curriculum regulated also the content of PE classes. The philosophy of the new curriculum focused more on health objectives and on the cognitive contents enabling emotional and social development. Beside the daily PE policy, a national health-related physical fitness surveillance system (so called NETFIT) was introduced in 2015, which monitors students’ fitness level on an annual basis (Kovacs et al., 2018[16]).
Austria: “Move children healthy 2.0”
“Move children healthy 2.0” (Kinder gesund bewegen 2.0) is Austria’s largest sport and school programme (Fit Sport Austria, 2016[17]). Its aim is to build co-operation between sports clubs and primary schools to provide children with the opportunity to take part in age-appropriate, diverse and joyful exercise programs free of charge. “Move children healthy 2.0” also targets educators, teachers and parents in recognition of their significant influence on the activity level and behaviour of children. The initiative started in 2009 under the name “Move children healthy” (Kinder gesund bewegen) and is implemented by the three Sports for All organisations (ASKÖ, ASVÖ and SPORTUNION) through local sport clubs. It is co-ordinated by the non-profit organisation Fit Sport Austria and funded by the Austrian Federal Ministry for Arts, Culture, the Civil Service and Sport.
Lithuania: Physical activity after school provided by the informal education financing system
Physical activity after school is provided by the informal education financing system, whereby allocations are distributed from the national budget to municipalities according to the number of schoolchildren. Informal programmes are offered by sports clubs, free-lance teachers, municipal sport centres and others. Municipal budgets also provide for sports services and activities for children (WHO, 2021[11]).
Estonia: Schools in Motion
The Schools in Motion programme in Estonia takes a whole-school approach, covering physical education, active recess, active lessons and active transport to and from school (Mooses et al., 2021[18]). Participating schools are supported through seminars, workshops and skills training, and have access to easy-to-use materials and research, for example tips on how to make the indoor and outdoor environment more physical activity friendly, and techniques for reducing sedentary time during classes. Using these resources, each school can develop their own action plan. In 2021, there were 148 participating schools (28% of all general education schools) with more than 63 000 students (WHO, 2021[11]).
Belgium: Financial aid for after-school activities
In Belgium, the Agency for Infrastructure in Education (AGION) and Sport Vlaanderen provide subsidies to open sports and physical activity infrastructure after school. Schools can apply for a grant of up to EUR 140 000 for secondary education and up to EUR 160 000 for preschool and primary education (AGION, 2021[19]).
Poland: Student Sports Club Programme
The Student Sports Club Programme is a nationwide programme aimed at promoting physical activity among primary and secondary school students. It has been run by the Ministry of Sport and Tourism since 2017, and systematically organises extra-curricular sports activities conducted by physical education teachers in schools. Students participate in 60 minutes of activities twice a week in various sports. Every year, over 330 000 students and more than 14 000 teachers participate in the programme. In 2020, the Student Sports Club activities were held in almost 9 000 schools in all regions of Poland.
Workplace-based programmes
As many adults spend a large portion of their lives in the office, workplace-based actions are increasingly considered as an effective tool to influence lifestyle (OECD, 2019[20]). Actions can target behaviour in the workplace, such as reducing sedentary behaviour by encouraging walking breaks and stair use, or focus on transport to and from the office (Box 4.4). In 2021, 20 out of 27 EU Member States had national guidance or a programme to promote physical activity in the workplace, and 17 had national guidance or a programme to promote active travel to work (WHO, 2021[11]).
Interventions to reduce sedentary behaviour are of particular importance for desk-based work environments, where employees spend a large part of their day being sedentary. These interventions can be educational strategies, such as counselling, behavioural strategies, like point-of-decision prompts to take the stairs, or environmental strategies, such as standing desks (Chu et al., 2016[21]).
Previous OECD modelling estimated that implementing programmes to combat workplace sedentary behaviour in 36 countries could prevent 232 000 cases of cardiovascular disease and 222 000 cases of diabetes over 2020-50, and increase GDP by 0.015% (OECD, 2019[20]). Moreover, due to the positive impact on health care expenditure, workforce size and productivity, for every EUR 1 invested in workplace sedentary behaviour programmes, EUR 4.1 is returned in economic benefits.
Ireland: Smarter Travel Workplaces and Smarter Travel Campus
The National Transport Authority operates the Smarter Travel Workplaces and Smarter Travel Campus behavioural change programmes on behalf of the Department of Transport, Tourism and Sport. The Workplaces and Campus programmes work with large employers and third level educational institutions to encourage more sustainable commuting and travel choices amongst their students and staff.
The Smarter Travel Workplaces programme helps companies promote walking, cycling, public transport, car sharing, the use of technology instead of travel, and flexible working practices. It offers promotional materials, such as posters on the benefits of walking; guides and other information, for example on how to set up a company-wide carpooling system or on developing a Workplace Travel Plan; and awards to successful examples. Larger companies can qualify for an online employee travel survey, analysis with a suggested Action Plan (National Transport Authority, n.d.[22]).
Bulgaria: Chair Up
Chair Up is a programme that helps people whose jobs involve sitting for long periods. The programme recommends workouts, physiotherapy and yoga therapy as well as remedial exercises that can be done in the office and at home. Monthly thematic programmes are proposed, as well as one-off training sessions on diverse topics. The general goals are to introduce a healthy, active lifestyle to people working in offices and at home; improve the health of employees; increase employee concentration, stress resistance and overall work efficiency; and raise the general awareness about sedentary behaviour. The Chair Up programme has already been implemented in companies, institutions and business centres reaching a total of more than 12 000 employees (Chair UP, 2020[23]).
Interventions in the health care sector
Health care professionals are well placed to provide advice on physical activity and its health benefits, as their opinion is generally respected and they come into contact with a large proportion of the population – including high-risk groups. Such advice can take the form of general behavioural counselling, or more formal prescribing of physical activity (OECD, 2019[20])(Box 4.5). In the EU, 18 out of 27 EU Member States had national guidance or a programme to promote counselling on physical activity or exercise prescription by health professionals in 2021 (WHO, 2021[11]).
The basic model of physical activity on prescription (PAP) programmes includes a personalised written prescription detailing the type, amount and intensity of physical activity. This prescription is takes into account the person’s health status, motivation and preferences. However, the design of PAP programmes varies across countries and regions: prescriptions can be written by GPs, nurses or other health professionals; the prescribed physical activity can be facility or home-based; and the programme duration differs (OECD, 2019[20]). Importantly, frequent meetings as well as subsidised or free access to sports facilities or exercise classes can improve the effectiveness of the programme, but also increases the cost.
Previous OECD modelling estimated that implementing PAP in 36 countries would prevent 236 000 cases of cardiovascular disease and 96 000 cases of diabetes over 2020-50 and increase GDP by 0.006% (OECD, 2019[20]). Moreover, for every EUR 1 invested in prescription of physical activity programmes, EUR 0.9 is returned in economic benefits – on top of the health and well-being benefits.
France: Sports – health houses
Sports – health houses (maisons sport-santé) were initiated by the ministries responsible for sports and health in 2019. There are currently 288 such centres throughout the country, and the goal is to have 500 by 2022. They may be hosted by public (e.g. hospitals, local authorities) or private structures (e.g. associations, sports and health networks). They organise information and awareness sessions and provide guidance and personalised support from health and sports professionals for sustainable practice of physical activity and sport, particularly for people who require adapted physical activity prescribed by a doctor, people with chronic diseases for whom physical activity is recommended and citizens in good health who want support to return to a physically active lifestyle (Ministère chargé des Sports, 2021[24]).
Netherlands: Combined lifestyle intervention
Since 2019, a combined lifestyle intervention has been included under the basic health insurance coverage in the Netherlands. It includes exercise on prescription for patients who have a body mass index ≥ 25 kg/m2 and another risk factor (e.g. risk factors for cardiovascular disease, type-2 diabetes) or a body mass index ≥ 30 kg/m2. General practitioners and specialists in primary health care refer patients to one of the qualifying combined lifestyle intervention programmes, which are provided by lifestyle coaches, dieticians, physiotherapists or exercise therapists. Participants receive diet and physical activity advice, as well as structured exercise classes, over a two-year period (RIVM, n.d.[25]).
Sweden: Prescribing of physical activity
Sweden has used the physical activity on prescription (PAP) intervention for 20 years, to address low levels of physical activity in the adult population (Onerup et al., 2019[26]). As part of the European Commission-funded EUPAP programme, the intervention is now being transferred to nine other EU Member States (EUPAP.org, n.d.[27]).
At the centre of the intervention is person-centred individualised counselling through a written prescription. This prescription notes the recommended type and dose of physical activity, possible contraindications and a plan for follow-up. To ensure that the prescription responds to the health needs of the individual, a handbook is available to prescribers which details evidence-based recommendations by disease. During a follow-up meeting the prescription can be adjusted. The patient can be referred to structured exercise through a community-based network of activity organisers, such as nongovernmental organisations, public or private facilities, but this handled and paid for by the patient, outside the health care system.
An OECD review of the PAP programme commended its strong evidence base and ongoing research on effectiveness. However, the uptake of the programme is limited compared to the size of the potential eligible population, and varies widely by region (OECD, 2022[28]).
Interventions in the sports sector
Sports facilities can play a major role in enabling and encouraging physical activity in the population (Box 4.6). Increasing public spending on recreational and sports services can increase the physical activity level for the population. OECD modelling estimates that, for Italy, an additional 1% investment could avoid more than 800 cases of cardiovascular disease annually, and it would be highly cost-effective (less than EUR 30 000 per DALY) as early as five years after the beginning of the intervention (Goryakin et al., 2019[29]).
Availability of and access to sports facilities is an important drivers of physical activity: 82% of people who exercise or play sports regularly say that they have many opportunities to do so in their local area, compared to 66% of people who never exercise (European Commission, 2018[30]). Opportunity is linked to socio-economic factors, as 79% of people who pay their bills without difficulty agree that they have sufficient opportunities in their area, but this falls to 59% among people who have difficulties paying bills most of the time. To ensure equitable access to sports facilities, such as sport pitches or gyms, they need to be available in the community, for people of all ages and abilities, at an accessible price.
Europe: “Sports clubs for health” programme
In addition to providing the opportunity to engage in sports, sports clubs can also take an active role in encouraging physical activity. The “Sports clubs for health” (SCforH) programme was designed to help sports clubs deliver programmes with a stronger focus on health and to encourage health-related activities. Instead of focusing on competition, Sports Clubs for Health emphasise recreational sports and increasing physical activity through sports.
Promoting physical activity within a sports club can be done by introducing new exercise methods, improving facilities, or developing tailored programmes for a specific target group (e.g. elderly people, newcomers or women). However, rather than an independent initiative, the aim is to integrate the SCforH approach into all the club’s activities. This includes restrictions on advertising of unhealthy food and drinks, health education, and coaches setting the right example with a healthy lifestyle.
Guidelines for the SCforH programmes have been prepared by a working group of Health-enhancing physical activity (HEPA) Europe and the Association for International Sport for All, supported by funding from the European Commission. They guide clubs through a Plan-Do-Check-Act process to develop their own SCforH initiative. They can be applied to any kind of sports club, regardless of the sports offered, size, whether it is voluntary or professional, or the age groups served (WHO, 2021[11]; Koski et al., 2017[31]).
Denmark: Get2Sport programme
The project Get2Sport under the Ministry of Immigration and Integration and the Sports Confederation of Denmark was started in 2005 with the aim of providing opportunities for children and young people in underprivileged areas to participate in sports, primarily football, in local clubs. The programme provides funding to hire employees for administrative task, to allow volunteers to focus on coaching and other sports-related functions. It can also provide support for other practical and resource challenges, such as transport to a match. In 2019, Get2Sport supported 55 associations in 43 vulnerable housing areas, located in 22 different municipalities (Danmarks Idrætsforbund, n.d.[32]).
Urban design, environment and transport policies
Physical activity is not just structured exercise and sport, but includes activities such as outdoor playing, recreational hiking and cycling to work. Urban design and the environment can facilitate these forms of physical activity by providing safe and pleasant spaces to move. Environmental policies to encourage physical activity can include regulation to improve road safety, urban planning requirements to increase parks, trails and other green spaces, and investments in dedicated cycling and walking lanes and other infrastructure.
One example is investing in public transport. Building new public transit options is estimated to increase the light to moderate physical activity of users by about 30 minutes per week, as people walk or cycle to transit stops (Xiao, Goryakin and Cecchini, 2019[33]). OECD modelling has shown that, on a population level, this can prevent 121 000 cases of cardiovascular disease and 37 000 cases of diabetes over the next 30 years across 36 countries, and raise GDP by 0.004% (OECD, 2019[20]). Transport policies can also focus on cycling (Box 4.7) and walking as active modes of transport.
Luxembourg: Bicycle Summer
Vëlosummer (Bicycle Summer) is a co-operative initiative between the Ministry of Mobility and Public Works, the General Directorate of Tourism and several municipalities. Certain roads were closed to motorised vehicles in the summer of 2020, and six routes were signposted, creating 550 km of additional cycle routes for 30 days. Cameras and road sensors were used to estimate that 40 000 cyclists took part in this “soft mobility-promoting” initiative. As a result of the successful 2020 edition, the number of collaborating municipalities tripled and the number of routes on offer doubled, so that over 600 km of cycling opportunities in Luxembourg were provided in 2021. Bicycle summer 2021 is expected to have encouraged more participants and cycling perspectives for the next edition 2022 (Visit Luxembourg, 2021[34]).
Germany: D-Netz cycle network
Originally started as a “D-Netz”, the German cycle network (Radnetz Deutschland) is an integral part of the measures of the Federal Government’s National cycling plan. In the network, Federal and state governments are committed to common standards and high-quality cycling tourism. The network, funded with EUR 45 million until 2023, consists of 12 long-distance cycle routes, the “German Unity Cycle Route” and the EuroVelo route “Iron Curtain Trail”. This network allows people to plan and experience a bike trip on safe, comfortable, relaxing routes by combining several thematic bike routes connecting all the regions of Germany (WHO, 2021[11]).
Design guidelines can help local governments and developers to create spaces that enable and encourage physical activity. The IMPALA guidelines were developed in Europe to support the development and improvement of infrastructure for physical activity (see Box 4.8). In 2021, only five out of 27 EU Member States reported that they applied the IMPALA guidelines systematically (WHO, 2021[11]). However, another 13 countries reported that they used similar national guidance or programmes.
Europe: IMPALA guidelines
The Improving Infrastructures for Leisure-time Physical Activity in the Local Arena (IMPALA) guidelines were developed through a collaboration of scientists and policy makers from 12 EU Member States, with funding from the European Commission. They consider three types of infrastructure: sports facilities, leisure time infrastructure (e.g. playgrounds, bike paths) and urban “green” and “blue” spaces (e.g. forests, beaches).
The guidelines identify ways in which infrastructure for leisure-time physical activity can be assessed and improved with a focus on social equity, inter-sectoral collaboration and participation. They are set across five key areas: policy making, planning, building, financing, and management. For example, for planning the guidelines provide advice on how to plan specific actions together with all relevant groups and stakeholders. Under financing, an overview is provided with the impact of different investor models, subsidies and funding procedures on equity issues as well as on collaboration between different policy sectors and levels. In Italy, the guidelines are included in general ministerial information kits and infographics (WHO, 2021[11]; IMPALA, 2011[35]).
Croatia: Healthy Living programme
The Healthy Living programme, managed by the Croatian Institute of Public Health, aims to improve the health of the population by reducing the negative impact of behavioural, biomedical and socio-medical risk factors and creating an environment in which all persons in Croatia are provided with the highest level of health and quality of life. One of the initiatives under the programme is the development of trails and parks in all 21 counties, to encourage physical activity. The design and equipment for these “exemplary parks” was created by a multidisciplinary collaboration among eight schools of the University of Zagreb (School of Medicine, School of Education and Rehabilitation Sciences, School of Kinesiology, School of Architecture, School of Design, School of Agriculture, School of Engineering and the Arts Academy). The project has been chosen for the Rector’s award for socially useful work (Zivjeti Zdravo, 2021[36]).
Information and communication policies
The first action of the WHO Global action plan on physical activity 2018-30 (WHO, 2018[37]) is to implement communication campaigns to increase awareness, knowledge and understanding of, and appreciation for, the multiple health benefits of regular physical activity. However, the messaging should not be limited to the health benefits, but also highlight the social, economic, and environmental co-benefits. Moreover, messaging should be inclusive, with images tailored to the diversity of communities (WHO, 2021[38]).
In 2021, 23 out of 27 EU Member States reported to have clearly formulated national campaigns for education and public awareness about physical activity (WHO, 2021[11]). While television, radio and newspapers remain commonly used media, 21 countries also reported using social media. However, while public awareness campaigns are an important part of any physical activity strategy, there are other information policies that can help promote physical activity, such as apps to locate resources (Box 4.9).
Spain: Localiza Salud
Localiza Salud is an online application that provides information about the availability of resources and activities in municipalities that contribute to health and well-being. All municipalities are invited to participate and map their resource to improve the lifestyles of their population. The strategy is used by 360 local entities, and more than 17 000 health-promoting resources have been published in the Localiza Salud application (Ministry of Health, 2021[39]).
Ireland: Campaigns in the context of COVID-19
During the COVID-19 pandemic, ongoing Healthy Ireland public information campaigns were re-purposed under the “In this Together” and “Keep Well” campaigns. These campaigns highlighted physical activity and individual sports that could be maintained in the context of necessary COVID-19 restrictions (e.g. exercise at home, online classes, walking, running, cycling, outdoor swimming if living near the sea/lakes). In late 2021, Sport Ireland and Healthy Ireland worked in partnership on the “Let’s Get Back” campaign, which encouraged a return to organised sport following the successful national vaccination campaign.
While all policies have their own benefits, it is unlikely that any single policy will have a major impact on physical activity levels in the population. Physical activity is a complex behaviour, which is influenced by many different factors, including personal variables such as motivation and physical ability; environmental factors such as schools, worksites, and other places where people spend most of their time; community characteristics determining the opportunity to exercise, as well as social factors such as peer pressure and public information (Bauman et al., 2012[40]). To increase physical activity, a comprehensive package of policies is needed to target all of these factors at the same time.
Previous OECD modelling work has shown how a physical activity policy package including interventions such as prescribing physical activity, investing in active transport and school-based programmes can lead to significant health gains and savings in health care expenditure. Such a package of policies aimed at increasing physical activity, implemented in 36 countries, would prevent 38 000 NCDs per year and save around EUR 14 billion in health cost by 2050 – equivalent to the total annual health care expenditure of Greece. Moreover, for every EUR 1 invested in a physical activity policy package, EUR 1.7 are returned in economic benefits (OECD, 2019[20]).
As with any public health strategy, it is crucial to ensure that the policy package has both financial and political support. Current funding for physical activity is often insufficient, short term, narrow in scope, and focussed on pilot and demonstration projects instead of strengthening a supportive system. Policy makers should set up sustainable and long-term funding (Box 4.10) (WHO, 2021[38]).
Germany: Preventive Health Care Act
The Preventive Health Care Act (Präventionsgesetz) was adopted in 2015 and aims to improve health promotion and prevention in Germany. The adoption of the law needs to be seen in the context of a federal health insurance system that relies heavily on statutory health insurances, which cover the costs of a broad range of health care services for large parts of the population. From an international perspective, the German health care system has traditionally had a strong focus on curative aspects while the role of prevention has been rather minor. Additionally, there is a high degree of governmental oversight of all aspects of the system.
Against this backdrop, the act has strengthened the role of prevention in the German health care system, including physical activity promotion. Firstly, new structures and institutions were created to improve the co-operation between important stakeholders, most importantly the National Preventive Conference (Nationale Präventionskonferenz). Secondly, a new mandatory Prevention Guideline (Leitfaden Prävention) for the German statutory health insurances defines physical activity promotion as an important action area for prevention measures. Statutory health insurances are obliged to invest at least EUR 7 annually per insured person in health promotion and prevention, resulting in a total of approximately EUR 500 million Out of this, at least EUR 300 million need to be invested in settings such as childcare, schools, communities, workplaces and nursing care. Thanks to the Preventive Health Care Act, total investment for health promotion and prevention has increased by around 40%, from EUR 1.3 billion in 2012 to EUR 1.8 EURO in 2017.
Overall, the Preventive Health Care Act is a comprehensive strategy that creates new opportunities for physical activity promotion, with substantial funds being allocated to this field. This includes funding for scientifically evaluated projects led or supported by researchers. It has been reported that the creation of new prevention structures is considered as very positive, even though co-operation between organisations could still be improved (e.g. with regards to a patchwork of projects which is yet to turn into a comprehensive network for prevention).
Source: Bundeszentrale für gesundheitliche Aufklärung (2021[41]), Präventionsgesetz, https://leitbegriffe.bzga.de/alphabetisches-verzeichnis/praeventionsgesetz/.
Moreover, while multicomponent, multilevel strategies are notoriously difficult to study, a comprehensive evaluation should be conducted to help understand whether the strategy works, what other impact it has, its value relative to the resources required to deliver it, how it interacts with the context in which it is implemented, and how it contributes to system change (Skivington et al., 2021[42]). An efficient data management and data linkage system to collect timely and accurate data can support evulation studies (Box 4.11).
Italy: PASSI
PASSI (Progressi delle Aziende Sanitarie per la Salute in Italia – Progress by local health units towards a healthier Italy) is a public health surveillance study based on continuous collection of information on lifestyles and behavioural risk factors related to non-communicable diseases among the Italian adult population. It was started in 2007 and is used to evaluate public health policy, such as the National Prevention Plan. Among other risk factors, PASSI collects information on both physical activity levels and active mobility (the use of cycling or walking to go to work, school or other usual trips).
Rather than one annual cross-sectional survey, the PASSI survey is based on a monthly random sample of people aged 18-69 years, stratified by sex and age groups, from each local health unit, to allow continuous monitoring. It is designed in such a way that the monthly samples can be used to calculate accurate annual estimates. Each year the national sample consists of about 35 000 interviews.
Source: EpiCentro (2021[43]), PASSI, https://www.epicentro.iss.it/passi/.
The task at hand is clear: make physical activity a public health priority to improve health and reduce the burden of non-communicable diseases. However, to achieve such a goal, much work remains. Rather than falling under strategies for other risk factors, physical inactivity should be a separate and equal concern, and should be recognised as a unique specialty. A strong policy framework, consistent investment in physical activity programs and infrastructure, multi-sectoral support, high population reach, and good surveillance should characterise each future action (Pratt et al., 2015[44]). Adaptation of the evidence-based strategies to community need, culture, and context is critical. An isolated public health strategy for physical activity is unlikely to be successful as many of the necessary actions occur in sectors other than public health and because sustained funding is nearly impossible without the broader political support associated with strong partners.
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