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Lausanne, February 2014Mandated by the Swiss Federal Office for Public Health (FOPH)

Division of International Affairs

Best Practices in Sport and Physical Activity for Health Promotion A Comparative Study of Selected National Policies

Viktoria Ivarsson

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E X E C U T I V E S U M M A R Y

This study aims to demonstrate the complementarity of sports and health policy. The complementarity is shown by comparing and contrasting the health-enhancing physical activity (HEPA) promotion policies of several countries with varying approaches. The study builds on previous policy analyses and physical activity recommendations to put forward a set of best practices illustrated by examples, which may be of special interest to policy-makers in Switzerland. The starting point is the identification of the relevant public entities responsible for sports at a national level. We examine the extent to which these entities have drafted policies on physical activity for health promotion. Where sports policy does not detail HEPA objectives, we turn to other parts of the public administration to find the relevant institution responsible for its definition. All relevant policies are then examined in detail to understand their scope and desired impact, as well as the mechanisms they provide for the implementation and evaluation of their objectives.

For the purpose of this study, we have selected the following countries:

• Australia, for its federal structure and its particular feature of a main sports agency as an integrated part of its department of public health as well as its physical activity strategies always referring to both “sports and active recreation”;

• the UK, due to its recent hosting of the Olympic Games and its desire to increase physical activity levels in the population as part of that legacy;

• Hungary, which substantially increased its sports-specific budget recently using a unique funding approach to counteract its poor rating in studies showing the proportion of the population engaging in regular physical activity;

• France, where the public health strategy is defined as an interplay of nutrition and physical activity; and

• Sweden, where the sports movement is responsible for the government’s sports and physical activity policy in close collaboration with other institutions.

We identify the best practices from each of the above national policies and suggest which ones may be of special interest to Switzerland. Based on these findings we propose a simple framework for effective sports and physical activity promotion at a national level.

EXECUTIVE SUMMARY

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Cette étude vise à démontrer la complémentarité des politiques de sport et de santé en comparant les politiques de promotion d’activité physique ayant des effets positifs pour la santé (HEPA) de différents pays recourant à des approches différentes. Elle s’appuie sur de précédentes politiques et recommandations en matière d’activité physique afin de faire ressortir un ensemble de bonnes pratiques qui puissent intéresser les responsables politiques en Suisse. Le point de départ est l’identification des entités publiques responsables pour le sport au niveau national. Nous examinons dans quelle mesure celles-ci ont défini des politiques en matière d’activité physique pour la promotion de la santé. Lorsque la politique en matière de sports n’énumère pas les objectifs de l’activité physique ayant des effets positifs pour la santé (HEPA), nous examinons d’autres secteurs de l’administration publique pour trouver l’institution responsable de cette définition. Chaque politique est ensuite examinée en détail pour en comprendre la portée et l’impact recherché, ainsi que les mécanismes pour la mise en œuvre et l’évaluation des objectifs.

Pour les besoins de cette étude, nous avons sélectionné les pays suivants :

• l’Australie, pour sa structure fédérale et sa particularité d’avoir intégré une principale agence de sports dans son département de santé publique, ainsi que pour ses stratégies d’activité physique se référant toujours à la fois « aux sports et aux loisirs actifs » ;

• le Royaume-Uni, en raison de sa récente organisation des Jeux Olympiques (Londres 2012) et de sa volonté d’accroître le niveau d’activité physique de la population comme un “héritage” de ces jeux ;

• la Hongrie, qui a récemment considérablement augmenté son budget spécifique aux sports en utilisant une approche unique de financement pour remédier à sa mauvaise réputation dans les études mentionnant la proportion de la population pratiquant une activité physique régulière ;

• la France, où la stratégie de santé publique est définie comme interaction entre la nutrition et l’activité physique ; et

• la Suède, où le monde sportif est en charge de la politique gouvernementale en matière de sport et d’activité physique en étroite collaboration avec d’autres institutions.

Nous identifions les meilleures pratiques de chacun de ces pays et suggérons celles qui peuvent intéresser tout particulièrement la Suisse. Sur la base de ces résultats, nous proposons un cadre pour une promotion efficace du sport et de l’activité physique au niveau national.

RÉSUMÉ

R É S U M É

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Diese Studie hat zum Ziel, die Komplementarität von Sport -und Gesundheitspolitik zu demonstrieren. Dies soll anhand eines Vergleichs und einer Gegenüberstellung von gesundheitsfördernden körperlichen Aktivitäten (HEPA) von Ländern mit unterschiedlichen Förderungsansätzen aufgezeigt werden.

Die Studie baut auf Analysen bisheriger Richtlinien zur körperlichen Aktivität auf. Aufgrund dieser Empfehlungen unterstreicht sie besonders erfolgreiche und für Schweizer Politiker interessante Vorgehensweisen. Diese werden anhand der folgenden Beispiele veranschaulicht. Ein wichtiger Ausgangspunkt ist die Identifikation der relevanten Stellen der Verwaltung, die auf nationaler Ebene für Sport verantwortlich sind. Wir untersuchen, in welchem Umfang diese Stellen Richtlinien für körperliche Aktivitäten zur Gesundheitsförderung erarbeitet haben. In den Fällen, in denen die Sportpolitik nicht näher auf HEPA Ziele eingeht, schliessen wir andere Bereiche der öffentlichen Verwaltung des jeweiligen Landes ein, um die letztendlich für die Definition und Zielsetzung verantwortlichen Institutionen zu finden. Jede strategische Zielsetzung wird dann im Detail untersucht, um ihren Umfang und ihre gewünschte Wirkung sowie die Mechanismen, die sie für die Durchführung und Bewertung ihrer Ziele anwendet, zu verstehen.

Folgende Länder wurden zum Zweck dieser Studie ausgewählt:

• Australien (aufgrund der föderalen Struktur und der Besonderheit bezüglich der Integration der Sport-Agentur im Ministerium für Gesundheit sowie aufgrund der Strategien für körperliche Aktivitäten, die auf “Sport und Erholung“ abzielen),

• Großbritannien (aufgrund der kürzlichen Austragung der Olympischen Spiele und dem damit verbundenen Wunsch körperliche Aktivitäten in der Bevölkerung zu erhöhen),

• Ungarn (das kürzlich nach schlechten Abschneiden in Studien sein sportspezifisches Budget mit einem einzigartigen Finanzierungskonzept massiv erhöht hat),

• Frankreich (wo die Gesundheitsstrategie als Zusammenspiel zwischen Ernährung und körperlicher Aktivität definiert ist) und

• Schweden (wo die Sportbewegung in enger Zusammenarbeit mit anderen Institutionen Einfluss auf die politischen Entscheidungen bezüglich Sport hat).

Für jede dieser nationalen Strategien identifizieren wir die optimale Vorgehensweise und führen jene Ansätze auf, die für die Schweiz von besonderem Interesse sind. Auf dieser Grundlage schlagen wir einen strategischen Rahmen für eine effektive Sport-und Bewegungsförderung auf nationaler Ebene vor.

ZUSAMMENFASSUNG

Z U S A M M E N F A S S U N G

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Table of Contents

List of Figures

1. List of Figures 5

2. List of Abbreviations 6

3. Introduction 7

4. 5 National Policies on Sport for Health Promotion Examined 9

4.1. Australia 10

4.2. UK 12

4.3. Hungary 14

4.4. France 17

4.5. Sweden 19

5. Best Practices 22

6. Conclusion 26

7. References 28

8. Webliography 30

9. Acknowledgements 31

FIGURE 1: WHO Recommended Levels of Physical Activity for Health 8

FIGURE 2: World Day for Physical Activity 9

FIGURE 3: Active After-School Communities (AASC) Programme 11

FIGURE 4: Recommendations from the Report on Improving Health Through Participation in Sport 13

FIGURE 5: Excerpts from Prime Minister Viktor Orbán’s Speech 18.06.13 15

FIGURE 6: “It’s Easier Together” Life-style Changing Team Competition for Workplaces 16

FIGURE 7: FYSS and FaR® 20

FIGURE 8: Comparative Infographic 21

FIGURE 9: Comprehensive Physical Activity Policies 22

FIGURE 10: Ten Key Points for Policy-makers 25

FIGURE 11: The 5 Cs of Sport for Health Promotion 27

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AASC Active After-School Communities

ASC Australian Sports Commission

DCMS UK Department for Culture, Media and Sport

EC European Commission

ERASS Australian Exercise, Recreation and Sport Survey

EU European Union

FaR® Physical Activity on Prescription (Sweden)

FOPH Swiss Federal Office of Public Health

FOSPO Swiss Federal Office for Sport

FYSS Physical Activity in the Prevention and Treatment of Disease (Sweden)

HEPA Health-Enhancing Physical Activity

INPES French National Institute of Health Prevention and Education

IOC International Olympic Committee

IPAQ International Physical Activity Questionnaire

ISEH UK Institute of Sport Exercise and Health

MOSEB Swiss Nutrition and Physical Activity Monitoring System

NCD Non-Communicable Disease

NGO Non-Governmental Organisation

NIHD Hungarian National Institute for Health Development

PNNS French National Nutrition and Health Program

L I S T O F A B B R E V I A T I O N S

LIST OF ABBREVIATIONS

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The World Health Organisation (WHO), as well as scholars and health practitioners worldwide, have highlighted the risks posed by rising levels of physical inactivity and increasing sedentariness worldwide. Alarming statistics show that physical inactivity has been identified as the fourth leading risk factor for global mortality, with “major implications for the prevalence of non-communicable diseases (NCDs) such as cardiovascular disease, diabetes and cancer and associated risk factors such as raised blood pressure, raised blood sugar and overweight” (WHO 2010, p. 10). Trends are equally disquieting in developed and developing countries. In its 2010 Global Recommendations on Physical Activity for Health, the WHO outlined a series of measures that were based on reducing levels of inactivity through the promotion of physical and sporting activities (see Figure 1). In it, policy-makers were “encouraged to incorporate the global recommended levels of physical activity for health to national policies, taking into consideration the most adequate and feasible options according to their needs, characteristics, physical activity domain and national resources while aiming to be participatory and socially inclusive, particularly of the most vulnerable groups” (WHO 2010, p. 36).

The international health sector’s ability to mobilise resources and galvanise action on key issues is a success story in implementing change at a policy and behavioural level. “Public health has a history of identifying, committing to, mobilising for, and successfully resolving health crises… The same resolve, strategies, and resources must now be applied to address physical inactivity and NCDs… by adapting and re-orienting existing capacity, developing creative new strategies, and capitalising on new and existing partnerships and networks” (Bull et al. 2006, p. 132). While international organisations such as the WHO and various non-governmental organisations (NGOs) have a key role to play, national governments, including Switzerland,

are also increasingly defining physical activity promotion objectives as part of their public policy. We are interested in taking a closer look at how these policies are structured, implemented, monitored and evaluated, with a view to surfacing new ideas that may be of interest to Swiss policy-makers in this field.

Our study considers a set of 5 national sports policies and examines the extent to which they address health promotion objectives, including goals on participation in sport and physical activity for health benefits. Where physical activity promotion is not detailed in the national sports policy, we dig deeper to look at which public office is responsible for promoting it. With refe-rence to extensive literature on implementing physical activity programs for health promotion, combined with selected national policy documents, as well as reviewing previous analyses of national sports policies, we create a set of country profiles which present how physical activity is promoted in these 5 countries. In so doing, we are able to compile a set of best practices out-lining ideas and tried and tested ways and means of fostering effe- ctive application of health-enhancing physical activity (HEPA). These then help us identify a set of fundamental factors that are key to the successful implementation of such policies.

By “best practices”, we understand concrete examples of the implementation of ideas to achieve determined objectives that have potential or proven success in their application. It is not our goal to reiterate the findings of other studies that enumerate how to promote physical activity, but rather to specifically see how a selection of different governments understand the imperative to do this, how they have defined policy objectives and to which governmental institution they have given this mandate. We supplement this analysis by detailing some of the projects and programmes they are involved in, which we believe may be of interest.

I N T R O D U C T I O N

INTRODUCTION“The doctor of the future will

give no medicines, but will interest his patients in the care

of the human frame, in diet, and in the causes and prevention of disease.”

(Thomas Edison, 1902)

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FIGURE 1:

WHO RECOMMENDED LEVELS OF PHYSICAL ACTIVITY FOR HEALTH (WHO 2010, P. 7-8)

5–17 years old

“For children and young people of this age group physical activity includes play, games, sports, transportation, recreation, physical education or planned exercise, in the context of family, school, and community activities. In order to improve cardiorespiratory and muscular fitness, bone health, cardiovascular and metabolic health biomarkers and reduced symptoms of anxiety and depression, the following are recommended:

1. Children and young people aged 5–17 years old should accumulate at least 60 minutes of moderate- to vigorous-intensity physical activity daily.

2. Physical activity of amounts greater than 60 minutes daily will provide additional health benefits.

3. Most of daily physical activity should be aerobic. Vigorous-intensity activities should be incorporated, including those that strengthen muscle and bone, at least 3 times per week.

18–64 years old

For adults of this age group, physical activity includes recreational or leisure-time physical activity, transportation (e.g. walking or cycling), occupational (i.e. work), household chores, play, games, sports or planned exercise, in the context of daily, family, and community activities. In order to improve cardiorespiratory and muscular fitness, bone health and reduce the risk of NCDs and depression the following are recommended:

1. Adults aged 18–64 years should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week, or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week, or an equivalent combination of moderate- and vigorous-intensity activity.

2. Aerobic activity should be performed in bouts of at least 10 minutes duration.

3. For additional health benefits, adults should increase their moderate-intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous-intensity aerobic physical activity per week, or an equivalent combination of moderate- and vigorous-intensity activity.

4. Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.

65 years old and above

For adults of this age group, physical activity includes recreational or leisure-time physical activity, transportation (e.g. walking or cycling), occupational (if the person is still engaged in work), household chores, play, games, sports or planned exercise, in the context of daily, family, and community activities. In order to improve cardiorespiratory and muscular fitness, bone and functional health, and reduce the risk of NCDs, depression and cognitive decline, the following are recommended:

1. Adults aged 65 years and above should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week, or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week, or an equivalent combination of moderate- and vigorous-intensity activity.

2. Aerobic activity should be performed in bouts of at least 10 minutes duration.

3. For additional health benefits, adults aged 65 years and above should increase their moderate- intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous- intensity aerobic physical activity per week, or an equivalent combination of moderate- and vigorous- intensity activity.

4. Adults of this age group with poor mobility should perform physical activity to enhance balance and prevent falls on 3 or more days per week.

5. Muscle-strengthening activities should be done involving major muscle groups, on 2 or more days a week.

6. When adults of this age group cannot do the recommended amounts of physical activity due to health conditions, they should be as physically active as their abilities and conditions allow.”

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The use of several case studies enables us to paint a comprehensive picture of the HEPA policy milieu and give better weight to the elements that are key to the success- ful implementation of these measures. Furthermore, a timely consultation of policies as currently implemented builds on previous analyses to give an up-to-date overview of the recent developments and innovations in this field. We have chosen to look more closely at 5 different countries with programmes that vary in scope, budget and structure.

By “national policies on sport and physical activity for health promotion”, we understand the public set of guidelines defined by governmental institutions to decrease levels of inactivity in the general population. “Such plans generally consist of a series of policy and/or practice recommendations intended to increase population levels of physical activity. The format of national plans varies widely by country. Some are included in a single, comprehensive physical activity strategy or action plan, but others are contained in multiple sources, including official policy documents, general public health strategy or action plans, web sites, and manuals” (Bornstein et al. 2009, p. 245).

In practice, we found that objectives on the use of sport and physical activity for health promotion were usually defined in two ways:

Either in the overall national sports policy, which also tends to include elite sport competition and other sporting objectives, or the national public health policy, where the physical and sporting activity component is often closely aligned to directives on nutrition. This substantiates the findings of other studies that have analysed national policy documents on the promotion of sport and physical activity, which are referenced herewith (notably WHO 2011, and Daugbjerg 2009). As well as strategy documents, we consulted the official websites and looked at any other digital presence of the relevant institutions or departments for further details on how the strategies are put into action and communicated. For example, a number of countries have an official presence on Twitter for their institutions and/or representatives.

The findings of these analyses are compiled in the form of country profiles. These identify the main institutions responsible for sport and physical activity for health promotion, describe their structures and scope, as well as give a sense of some of the current projects that are implemented for this purpose. Some up-front figures provide a socio-economic context and give additional points of reference for a comparison between countries (see Figure 8). For the purpose of this study, we have chosen to compare and contrast Australia, the United Kingdom (UK), Hungary, France and Sweden.

5 NATIONAL POLICIES ON SPORT AND PHYSICAL ACTIVITY PROMOTION EXAMINED

FIGURE 2: World Day for Physical Activity (http://www.portalagita.org.br/en/agita-mundo/who-we-are.html)

Agita Mundo is a programme modelled on Agita Brazil, which is supported by the Brazilian Ministry of Health, and also has reach beyond the country with Agita America. Agita Brazil became the Brazilian national strategy for physical activity promotion, galvanising local and community events and simple measures to decrease inactivity, such as encouraging walking, biking, and favouring stairs instead of elevators. In 2002, it came to the attention of the WHO, who highlighted the pioneering model. The 54th World Health Assembly decided that the World Health Day of would have as its theme the promotion of physical activity. Since then, April 6 was maintained as the World Day of Physical Activity. Agita Mundo is a network supported by institutions worldwide that prone a very hands-on approach to translating theory to practice, which aside from coordinating the World Day of Physical Activity is engaged in achieving the following objectives:

• “Advocate for physical activity and health through an annual Move for Health Day, other community based and community wide events, and informing policy makers of the importance of physical activity to public policy.

• Widely disseminate a clear, simple and consistently delivered message on the health and social benefits of at least 30 minutes of moderate physical activity every day.

• Stimulate the creation of regional and international networks for physical activity promotion and provide linkages between these networks.

• Promote and disseminate about innovative approaches to develop alliances around the world to promote physical activity and good health.

• Share good practices and effective strategies and programs through websites, meetings, workshops and publications.”

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The entity responsible for Australia’s sports strategy and funds is the Australian Sports Commission (ASC), an agency of the Australian Government, which sits within the portfolio of the Department of Health since September 2013. This in of itself highlights the linkage between sporting activities and health promotion. The Minister for Sport appoints a group of commissioners who form its board and are responsible for governing the Commission and its budget. On June 2011, the Government of the Commonwealth of Australia agreed to a National Sport and Active Recreation Policy Framework, a framework that sets out the major targets for Australian sports development, including in HEPA promotion. The foreword qualifies this as follows: “The Framework is not a policy document but provides a guide for the development of policies by all governments (of the Territories of Australia). It is intended that coordinated strategies and initiatives that flow from the Framework will lead to greater alignment of sport and active recreation funding and programs in pursuit of an improved sport and active recreation system” (Australia 2011, p. 3).

The scope of HEPA promotion is clearly defined through the inclusion of both “sport” and “active recreation” in such a way that organised institutionalised games and recreational physical activities are both included in the policy. We found this to be the case throughout Australia’s HEPA policy discourse. Each of the roles and responsibilities within the Sport and Active Recreation System of the different levels of government, that is, Commonwealth, State and Territory Governments, are clearly set forth and described in some level of detail. This is taken a step further by also detailing the expected contributions from other stakeholders deemed key in this process, such as local governments, sporting and

recreation organisations at various levels, and clubs, associations and private companies.

A Committee of Officials reporting to the Council of Sport and Recreation Ministers is set up to implement regular monitoring progress, and report to the Council. The process in itself is not described, but there is a commitment to annual reports being “collated in a format which will enable ready analysis” (Australia 2011, p. 15). However, a series of priority areas are stated with specific measures on how success will be measured for each of these targets. For example, for the objective of increasing participation in sport and active recreation, success is measured by observing an increase in the number of Australians participating regularly in sport and active recreation, including membership of paid, events- based, school-based and program-based activities (Australia 2001, p. 16). The Framework itself was to be reviewed in 2013 and thereafter every 4 years.

While the health benefits of sport are alluded to by the Commission in the strategy documents, the Department of Health, of which the Sports Commission is a part of, also covers physical activity for health promotion in its own policy, as is suggested by the name of this part of their website (http://www.healthyactive.gov.au). It also includes links to a number of physical activity publications and recommen-dations. The strategy is articulated along a series of 14 long term goals, of which the first is Population Health and specifically refers to promoting physical activity: “a reduction in the incidence of preventable mortality and morbidity in Australia, including through regulation and national initiatives that support healthy lifestyles and disease prevention” (Australia Department of Health 2011, p. 54).

Population (millions): 22.3

GDP (US$ billions): 1,541.8 GDP per capita (US$): 67,723 GDP (PPP) as share (%) of world total: 1.17 (World Economic Forum 2013, p. 110)

Institution Responsible for HEPA: It should be noted that until recently, sport was the aegis of the former Department of Regional Australia, Local Government, Arts and Sport, under which the main sports authority, the Australian Sports Commission (ASC) operated. In September 2013, the ASC became a part of the portfolio of responsibilities of the Department of Health. So while HEPA was previously informed by the strategies of two separate departments, these are now all under the same governmental institution.

http://www.ausport.gov.au, http://www.health.gov.au

Twitter account: @Ausport, @HealthgovauPer capita government expenditure on health at average exchange rate 2011 (US$):

4068.8 (WHO Global Health Observatory Data Repository, http://apps.who.int/gho/data/view.main.1920ALL?lang=en)

Australia

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FIGURE 3: The Australian Sports Commission’s Active After-School Communities (AASC)

Programme: Helping Children and Communities Get Active

This is a government-sponsored programme run in 3270 schools and after-school care centres throughout Australia which provides free activities and healthy snacks for children to partake in activities after the usual school day, between 15.00 and 17.30. It includes coordinators and trained coaches who help implement the programmes, and resources to assist local clubs and sports associations to develop their offering for juniors. In 2010, the ASC mandated an independent auditor for a detailed evaluation of the programme (which has run since 2005), who made the following key observations on changes in levels of physical activity behaviours (Newspoll 2011, p. 28):

“There is evidence that the AASC programme is decreasing sedentary behaviour after school. Most children who attend do so frequently and regularly. Although most have alternative after school physical activities available to them in their local communities (55%), most would not use these activities (46%). There is evidence of replacement behaviour for a small minority only (10%). Half of parents (52%) say their child would be engaged in sedentary behaviour at least some of the time they are participating in AASC program. Children who would have been physically active if they were not attending the AASC programme would mainly have been physically active in an unstructured way.”

http://www.ausport.gov.au/__data/assets/pdf_file/0004/317281/AASC_general_brochure_v3.0_-_21_2_12.pdf

http://www.ausport.gov.au/__data/assets/pdf_file/0003/445116/Report_Program_Monitoring_Wave_2_Final_21.pdf

The strategy states that this will include “helping Australians to participate in more sport and active recreation through a boost to sports funding” (ibid.). Each objective is described by giving an overview of its related programmes, detailing the associated budget and staffing, as well as specifying “indicators and targets used to assess and monitor the performance of the Department of Health and Ageing in achieving Government Outcomes” (ibid.).

The use of a comprehensive survey and interviews to research active participation figures in the country is a best practice also worth noting. The Exercise, Recreation and Sport Survey (ERASS) was conducted annually in collaboration with State and Territory Departments of Sport and Recreation between 2001 and 2010. (Since 2011 due to changes in internal structuring and budgeting, the Australian Bureau of Statistics runs the Survey). The Survey allows for detailed analysis of trends across the country for the “frequency, duration, nature and type of physical activities participated in for exercise, recreation or sport by persons aged 15 years and over” (ERASS 2010, p. 1). These figures provide policy-makers with concrete data on the practice of different population groups arranged by gender, age, family situation, socioeconomic status, and so on. There is an annual report detailing the results and methodology for each year the survey has been undertaken.

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For the United Kingdom we have chosen to focus our analysis on Sport England, which is the brand name of the English Sports Council under the UK’s ministerial Department for Culture, Media and Sport (DCMS). While one of the main areas of focus for the Department is the legacy of the London 2012 Olympic and Paralympic Games, “Getting more people playing sport” was reiterated as a key priority earlier this year, with a renewed commitment to additional funding for Sport England for this very purpose (https://www.gov.uk/government/policies/getting-more-people-playing-sport).

In 2012, the DCMS launched a new strategy aimed at youths called “Creating A Sporting Habit for Life”. Using the motto of the London 2012 Olympics “Inspire a Generation”, the goal of the strategy is to “inspire a generation of young people to take up sport as a habit for life” (DCMS 2012, p. 3). Sport England is therefore mandated to achieve the following objectives: “We are seeking a consistent increase in the proportion of people regularly playing sport. In particular, we want to raise the proportion of 14-25 year olds who play sport and to establish a lasting network of links between schools and sports clubs in local communities so that we keep young people playing sport up to and beyond the age of 25” (DCMS 2012, p. 3). 5 programmes are detailed, with some indications on budget and specific targets, although this tends to vary from programme to programme.

The aim of these programmes is to change habits and behaviours as a result of the Olympic Games coming to the country. This represents a unique opportunity to inspire youths in particular not only to take up physical activity, but to continue practicing it into their adult lives. This is to be achieved by the following means (DCMS, 2012, p. 3-4):

• “Building a lasting legacy of competitive sport in schools – the School Games provides a framework for competitive school sport at school, district, county and national levels – with lottery, public and private sector funding of over £150m secured until 2015. In addition, Physical Education will remain a compulsory part of the National Curriculum.

• Improving links between schools and community sports clubs – we will work with sports such as Football, Cricket, Rugby Union, Rugby League and Tennis to establish at least 6,000 partnerships between schools and local sports clubs by 2017… Our objective is that every secondary school and many primary schools will have links with at least one local club. In addition, every County Sport Partnership will have a dedicated officer responsible for making links between schools and community sports clubs in their local area.

• Working with the sports governing bodies: focusing on youth – we will ask those sports governing bodies, where young people are the main participants, to spend around 60 per cent of their funding on activities that promote sport as a habit for life amongst young people. We will ensure that sports are completely focused on what they

Population (millions): 62.7 GDP (US$ billions): 2,440.5 GDP per capita (US$): 38,589 GDP (PPP) as share (%) of world total: 2.81 (World Economic Forum 2013, p. 380)

Institution Responsible for HEPA:

Sport Englandhttp://www.sportengland.org

Twitter account: @Sport_EnglandPer capita government expenditure on health at average exchange rate 2011 (US$):

2984.3 (WHO Global Health Observatory Data Repository, http://apps.who.int/gho/data/view.main.1920ALL?lang=en)

United Kingdom

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have to achieve, with payment by results – including the withdrawal of funding from governing bodies that fail to deliver agreed objectives…

• Investing in facilities – a further £160m will be spent on new and upgraded sports facilities… This will include funding for the first time to allow schools to open up their sports facilities (three-quarters of all sports halls and a third of all swimming pools) to the public.

• Communities and the voluntary sector – we will also work with local authorities, voluntary groups and others to make the broadest possible sporting offer to young people… Overall, we are investing over £250m in community aspects of this strategy.”

Another best practice to note in this policy document is the reference throughout to success stories in the form of Case Studies, giving concrete illustrations of how past initiatives in a particular domain have effected change. Furthermore, as in the case of Australia, the DCMS and Sport England conduct a survey on participation in sporting activities.

It is particularly interesting to note that the DCMS and Sport England also ran an open public consultation “with users and other interested parties on proposals to change the way sport is measured in the Taking Part and Active People surveys” from May-August (https://www.gov.uk/government/consultations/sport-participation-measurement-consultation-on-proposed-changes).

In collaboration with the British Heart Foundation Health Promotion Research Group at the University of Oxford, an independent report was mandated by Sport England in 2012 to provide a comprehensive review of research and practice in “Improving Health Through Participation in Sport”. The results of this study are cited in Figure 4.

FIGURE 4: Recommendations from the Report on Improving Health Through Participation in Sport (Cavill et al. 2012, p. 3-4)

“Nine UK cases studies were identified (from over 200 initial contacts). These provided evidence that sport can reach inactive people especially if the programmes include the targeting of inactive people and are properly marketed, planned and delivered appropriate to the needs of the target group(s) by empathic motivating leaders… While the case study review showed that there are some approaches to monitoring that are effective, it also revealed that the majority of activity in this area is relatively unfocussed. In particular, data management has been shown to be poor in the vast majority of cases. Many projects started collecting data and then stopped, or collected baseline data and did not plan a follow-up. Some projects collected data but did not analyse it. Overall, it seems that the quality and quantity of monitoring and evaluation activity needs to be increased.

Recommendations:

Sports agencies (including governing bodies) should:

• Establish more robust systems for the evaluation of sports promotion projects, that enable an assessment of the effectiveness of the project in increasing participation in sport, ideally using a controlled research design;

• Plan programmes to target inactive people, including measurement of physical activity levels before and after the programme;

• Support project managers with training and guidance on targeting, marketing and monitoring.

Sport England should:

• Develop a strategy for improving health through sport;

• Develop an evaluation framework for sport projects that encourages the use of controlled research designs;

• Agree a standardised measure of physical activity for use by sport promotion projects;

• Support project managers with training and guidance on targeting, marketing and monitoring;

• Develop, fund and evaluate pilot projects that specifically set out to reach inactive people, and use a controlled research design;

• Ensure that pilot projects are sustainable and can be scaled up once the initial pilot funding ceases.”

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The Hungarian sports strategy (see Figure 5) came to the attention of the European Commission (EC) in 2011. The Hungarian government was proposing a new aid measure for supporting the Hungarian sports sector via a tax benefit scheme, and the EC had to review the proposal to assess whether it was in line with European Union (EU) anti-competition law. The Commission’s analysis provides us with a concise overview of the scheme.

The plan provides for the injection of State aid to boost the sports sector and encourage future market funding, with the overall objective of “increasing the participation of the general public in sport activities, by inter alia, promoting mass sport events, training of the young generations as well ensuring adequate sport infrastructure and equipment for the general public” (EC 2011, p. 19). The provision of subsidies is highly regulated by a Controlling Entity, under the Ministry of National Resources (which is responsible for Sport, as there is no sports ministry per se). In this strategy, every sports organisation may seek funding for their activities. Once the application is approved, every 3 months the sports organisation must submit a detailed statement on the use of the subsidy (including financial and accounting statements). The Controlling Authority can instigate field audits to verify the use of funds, and is itself also audited independently.

There is full transparency on the whole scheme, with details of each organisation’s request publically available. The Hungarian Government also reports annually to the EC on the details of their progress: “The monitoring report will inter alia contain information on the total aid amount allocated on the basis of this scheme, the sport infrastructure projects funded, their aid intensities, their beneficiaries, the parameters applied for benchmarking prices, the rents effectively paid by the professional sport organizations, as well as a description on the benefits provided to the general public and on the multifunctional usage of the infrastructures” (EC 2011, p. 13).

It may be early days to speculate on the success of this programme. With reference to the Prime Minister’s speech (see Figure 5), it is worth noting it was the low level of physical activity in Hungary compared to the rest of the EU that prompted an overhaul of the country’s sports strategy. In parallel and on a smaller scale, Hungary’s National Institute for Health Development (NIHD) has been coordinating some projects on behalf of the Ministry of Health which are specifically aimed at “restoring the balance between nutrition and exercise” (NIHD 2001, p. 1). One of these programmes, which suggests there is a greater rate of success in changing behaviours in team-oriented versus individual-oriented initiatives, is cited in Figure 6.

Population (millions): 10.0 GDP (US$ billions): 126.9 GDP per capita (US$): 12,736 GDP (PPP) as share (%) of world total: 0.24 (World Economic Forum 2013, p. 212)

Institution Responsible for HEPA:

Ministry of National Resources and the National Institute for Health Developmenthttp://www.oefi.hu/aboutus.htm

http://www.nefmi.gov.hu/english

Twitter Account: no official account

Per capita government expenditure on health at average exchange rate 2011 (US$):

702.6 (WHO Global Health Observatory Data Repository, http://apps.who.int/gho/data/view.main.1920ALL?lang=en)

Hungary

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FIGURE 5: Excerpts from Prime Minister Viktor Orbán’s Speech at the Opening of a New Sports Arena in Tamási on 18 June 2013 (http://www.kormany.hu/en/prime-minister-s-office/the-prime-ministers-speeches/prime-minister-viktor-orban-s-speech-at- the-inauguration-of-the-new-sports-arena)

“Hungarians’ relationship with sport has become extremely contradictory in recent decades. While Hungarian athletes almost always perform excellently in international competition, only 38% of young people in Hungary exercise regularly. According to surveys, Hungary is one of the four countries of the 27-member European Union that do the least sports. What used to go without saying for almost all children a few decades ago must now be actively taught to our children… In the two decades since the fall of communism, areas that are suitable for sports have slowly disappeared. Businesses and shopping centres have occupied the places of playing fields and pitches… After the 2010 elections we decided to transform the economy, transform education, transform law enforcement, and we must similarly transform the system of sport.

This is why we have developed (a new) system, with which we have successfully placed the future of the most popular sports such as handball, football, basketball and ice hockey onto new foundations… In 2014 a further 28 projects for handball will be opened in eight different locations… Had we been unable to develop (a new) financing system, which is an unprecedented financial solution in all of Europe, then Hungarian competitive sports would hardly be able to climb out of the pit

it is currently in. And in addition, within the upcoming days the Government will also decide on the signing of agreements with 16 further professional sports associations, which will include developing facilities and the training of young athletes in table tennis, athletics, wrestling, rowing, judo, kayak and canoe, cycling sports, ice skating, boxing, pentathlon, volleyball, shooting, tennis, gymnastics, swimming and fencing…

School children will also be able to use these faculties until four in the afternoon, and in fact it will be they who will use them the most… International studies have shown that children who do sports regularly at a young age not only become healthier adults but are also more intelligent. There is a proven link between physical activity and mental performance. And so if we neglect our children’s exercise, if we do not introduce everyday physical education, if we neglect their character building through sport, then children will not only become less healthy, but also less intelligent than they could otherwise be or we ourselves are. And accordingly, the responsibility we feel towards our children requires us to create all possible opportunities for our children to have a greater chance at achieving future success through everyday physical education.”

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FIGURE 6: “It’s Easier Together” Life-style Changing Team Competition for Workplaces (http://eurohealthnet.eu/sites/eurohealthnet.eu/files/images/Department%20of%20Lifestyle_NIHD.pdf)

“Objective of the programme:

To consciously change the life-style of the employees that enter the competition, in terms of healthy nutrition and regular exercise.

Target group of the programme:

Workplace communities

Description of the programme:

A collaboration of the Association for Healthier Workplaces (EMEGY, www.emegy.hu), the National Institute for Health Development (NIHD, www.oefi.hu) and the Hungarian Association for Recreational Sports (MSzSz, www.masport.hu), publishes a life-style changing competition for workplaces. It’s a nationwide call that targets regional, provincial, community and municipal levels.

The joining teams consist of 5-10 members that, in the interest of a healthier life-style, take on to change their nutritional and exercise behaviour. Every team member receives a booklet with guidelines for implementing life-style changes. Contact with the joining teams is maintained through the team captain on the Internet. The fitness-index of the participating teams is objectively monitored through the changes in BMI and the results to a 2 km walking test. These are measured at the beginning and the end of the project and form the competitive element. The programme organizers help out with the life-style changes through bi-weekly electronic newsletters.

Technical and financial aspects:

The costs of the press conference announcing the life-style changing competition. The rent of a sports field for the measurements at the beginning and end of the project, as well as for group training. The costs of professionals involved in the measurements, eventual commission for trainers; costs for measurement instruments (body mass index measuring device, scale, stopwatch). Finding sponsors for the costs of the publication of the results. Costs for the press conference announcing the results.

Results:

Life-styles can be changed more effectively if addressed in teams, as opposed to individual initiatives. Besides the advantages for the individual, the workplace also profits from healthier teams by their better performance, less absence, better working atmosphere, better internal communication and improved contact between colleagues. It is our experience, that the involvement of managers in the competing team has beneficial effects. The involvement of the local media will not only increase the effectiveness of the program, but will also help setting a good example and orientation. The model programme is easy to monitor with the help of a survey.”

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Promoting physical activity and sports is listed as the second area of focus for France’s National Nutrition and Health Programme (PNNS) 2011-2015, also known under its motto “Manger Bouger” (meaning “eat and move”). The strategy outlines four objectives and a series of sub-objectives within each category with very explicit time frames and targets. Objective 2 is dedicated specifically to physical activity:

“General Objective 2: Increase physical activity and decrease sedentary behaviour in all age groups.

General Sub-Objective 2-2: Increase physical activity and combat sedentary behaviour among children and adolescents.

Sub-Objective 2-2-1: Within 5 years, ensure that at least 50% of children and adolescents aged 3 to 17 practise some type of high-intensity physical activity three times a week for at least one hour” (Ministry of Health 2012, p. 25).

It is to be noted that this document is very thorough and precise, to the point and easy to read. Another best practice is the cross-referencing with other national policies in such a way that the approach is cross-sectoral: for example, promoting an environment that is conducive to increased levels of physical activity is to be achieved by “promoting and encouraging active modes of transport by incorporating active travel options in transport networks, in association with the second National Environment and Health Plan” (Ministry of Health 2012, p. 27). Employers, unions and local governments are also cited as key stakeholders. There are different resources offered to these stakeholders, as

illustrated by website www.mangerbouger.fr. The homepage is directed at the general public and includes information by areas (nutrition and physical activity) as well as person segmentation (children, adolescents, pregnant women and seniors). A separate thumbnail “for professionals” includes specific links for education, health, and social workers and community initiatives.

The other key lesson to learn from this document is the desire of the PNNS to position itself as the main strategy of reference in this domain, in order for actions in this field to be complementary and coordinated. A communication strategy is also outlined (Ministry of Health 2012, p. 36):

• “Creating a specific institutional web-portal for infor-mation regarding the PNNS, its principles, its actions, its major partners that are approved sources of information: http://www.sante.gouv.fr/nutrition-programme-national-nutrition-sante-pnns,6198.html (which can redirect to various approved sources);

• Promoting the www.mangerbouger.fr website as a leading online reference tool for information about “nutrition and health”;

• Informing the media, relevant professionals, elected representatives and the general public regularly regarding PNNS accomplishments;

• Increasing the prominence of the PNNS logo and its variants;

• Actively taking part in topical debates to highlight the messages of the PNNS”

Population (millions): 65.4 GDP (US$ billions): 2,608.7 GDP per capita (US$): 41,141 GDP (PPP) as share (%) of world total: 2.71 (World Economic Forum 2013, p. 186)

Institution Responsible for HEPA:

Ministry of Health and Social AffairsThe French Ministry of Sport, Youth, Popular Education and Community Life section on sport and health directs to the Ministry of Health and Social Affairs and the National Nutrition and Health Programme.

http://www.sante.gouv.fr

Twitter account: @Minist_SocialPer capita government expenditure on health at average exchange rate 2011 (US$):

3800.2 (WHO Global Health Observatory Data Repository, http://apps.who.int/gho/data/view.main.1920ALL?lang=en)

France

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This is complemented by facilitated creation of networks of actors implementing the PNNS through the signing up to a Charter for cities and regional government, as well as public and private entities, which are then referenced on an online database (http://reseauvillesactivespnns.fr). By becoming a signatory of the City Charter, a municipality commits to implementing at least one of the action items detailed in the PNNS a year, and names a representative who is accountable for reporting annually to the Regional Health Agency about what programmes are being run, and what is being planned plan for the following year. Furthermore, institutions can apply for the use of the PNNS logo. The purpose is to streamline messaging on nutrition and physical activity, and more broadly to ensure the overall coherence of information and actions implemented in France. A committee of experts is appointed to receive and treat requests for labels once a month based on a set of criteria for documents or for initiatives, which can be downloaded from the website.

The PNNS is also a benchmark in that it suggests a number of crosscutting elements that must be taken into account across the board, so-called “Transversal Components” (Ministry of Health 2012, pp. 41-47). They are: training, monitoring, evaluation and research, and also include a cross-border cooperation dimension through knowledge sharing at the European and international level.

In terms of monitoring, a Health and Nutrition Barometer was developed by the National Institute of Health Prevention and Education (INPES, www.inpes.sante.fr). This measure uses survey data on actual practice and people’s perception of their attitudes towards HEPA. Physical activity is broken down into 3 types: physical activity undertaken at work, as a means of transportation, or recreationally. For example, the 2010 Barometer showed that for the French population in general, recreational physical activity tends to decline with age, whereas the activity undertaken to get to places as a means of transportation increases (http://www.inpes.sante.fr/Barometres/barometre-sante-nutrition-2008/activite.asp). Such data can therefore be used to tailor strategies targeting particular population groups, or different activity types.

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In the Swedish Government, sport is part of the portfolio of responsibilities of the Ministry of Culture. However, since 1999, the role of the State in sport matters has largely been delegated to other institutions, led by the Swedish Sports Confederation. “The Government defines the aims and objectives for allocating grants to sports organisations… (and) the sports movement (represented by the Confederation) sets the goals of its activities itself” (Government Bill 2008/09:126, 2009, p. 1). The Swedish Sports Confederation therefore undertakes the work usually associated with a sports ministry or commission. The main objective of the Government in subsidising the sports sector is public health (ibid., p. 17, 18), and as a result the Confederation is responsible for ensuring that health is at the core of its strategy.

The Strategic Plan of the Swedish Sports Confederation’s public health work is called “Sports Throughout Life”, and is based on the Government’s 11 national public health target areas:

1. Participation and influence in society2. Economic and social security3. Secure and favourable conditions during childhood4. Healthier working life5. Healthy and safe environments and products6. A more health-promoting health care and medical

care system7. Protection against communicable diseases8. Safe sexuality and good reproductive health9. Increased physical activity10. Good eating habits and safe food11. Reduced use of tobacco and alcohol, a society free from

illicit drugs and doping and a reduction in the harmful effects of excessive gambling

Target 9, “Increased physical activity”, is listed as the first priority of the Swedish sports movement. To achieve this goal, the Strategic Plan includes local, regional, national and international cooperation perspectives, with specific partner organisations listed throughout. Two of them are especially important at the national level. First, the Swedish National Centre for Research in Sports establishes relevant monitoring indicators, including for the measurement of the effect of sports activities on public health. Second, the National Institute for Public Health establishes frameworks and guidelines to link physical activity theory to practice.

The collaborative nature of the Swedish undertaking when it comes to HEPA promotion is highlighted further in the many initiatives already underway that are also cited in the Strategic Plan. It is suggested that sports organisations become more involved with these existing initiatives. These include for example the data bank of the Professional Associations for Physical Activity, and the Physical Activity on Prescription methodology outlined in Figure 7.

Population (millions): 9.4 GDP (US$ billions): 526.2 GDP per capita (US$): 55,158 GDP (PPP) as share (%) of world total: 0.47 (World Economic Forum 2013, p. 356)

Institution Responsible for HEPA: Swedish Sports Confederationwww.rf.se

Twitter account: @RFidrottenPer capita government expenditure on health at average exchange rate 2011 (US$):

4314.5 (WHO Global Health Observatory Data Repository, http://apps.who.int/gho/data/view.main.1920ALL?lang=en)

Sweden

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FIGURE 7: FYSS and FaR®

The Professional Associations for Physical Activity are an independent sub-association of the Swedish Society of Sports Medicine. They are the keepers of an extensive knowledge bank on how to use physical activity in the prevention and treatment of NCDs, known as FYSS (for “Fysisk aktivitet i Sjukdomsprevention och Sjukdomsbehandling”, http://www.fyss.se/fyss-in-english/). In cooperation with the Swedish National Institute of Public Health (SNIPH) based on various pilots run in 2001, they have developed a handbook currently used in Sweden and Norway for the prescribing of physical activity by professional healthcare staff -- the so-called FaR® (for “Fysisk aktivitet på Recept”, Physical Activity on Prescription). This is a registered trademark for a methodology for promoting physical activity as a supplement to or in place of drugs, and is used by clinics and public health planner planners to provide the relevant theoretical context and a set of guidelines for how and why to implement physical activity on prescription.

It is based on 5 components:

1) A patient-centered approach and individualized prescription, 2) Physical activity in the prevention and treatment of disease, 3) Written prescription, 4) Collaboration with activity organizers and 5) Monitoring (http://www.fhi.se/Handbocker/FaR-Individanpassad-skriftlig-ordination-av-fysisk-aktivitet/FaR-i-praktiken-/).

At the core of the approach is a desire to respond specifically to the needs of the individual. Experience has shown that it is good to have a custom individual activity that can be pursued on a daily basis, and then based on the patients wishes this can be developed to include an organized activity. FaR® is therefore positioning itself as the bridge between the healthcare sector and physical activity providers, be they volunteer organizations, non-profit sports associations, senior citizens’ associations, patient associations, and municipal facilities or private entrepreneurs.

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FIGURE 8: Comparative Infographic

Source: World Economic Forum 2013 and WHO Global Health Observatory Data Repository

Population (millions): 62.7

GDP (US$ billions): 2,440.5

GDP per capita (US$): 38,589

GDP (PPP) as share (%) of world total: 2.81Institution Responsible for HEPA:

Sport Englandhttp://www.sportengland.orgTwitter account: @Sport_EnglandPer capita government expenditure on health at average exchange rate 2011 (US$):

2984.3

UK

Population (millions): 10.0

GDP (US$ billions): 126.9 GDP per capita (US$): 12,736

GDP (PPP) as share (%) of world total: 0.24Institution Responsible for HEPA:

Ministry of National Resources National Institute for Health Developmenthttp://www.oefi.hu/aboutus.htmhttp://www.nefmi.gov.hu/englishTwitter Account: no official accountPer capita government expenditure on health at average exchange rate 2011 (US$):

702.6

HungaryPopulation (millions): 65.4 GDP (US$ billions): 2,608.7 GDP per capita (US$): 41,141 GDP (PPP) as share (%) of world total: 2.71Institution Responsible for HEPA:

Ministry of Health and Social Affairshttp://www.sante.gouv.frTwitter account: @Minist_SocialPer capita government expenditure on health at average exchange rate 2011 (US$):

3800.2

France

Population (millions): 9.4

GDP (US$ billions): 526.2 GDP per capita (US$): 55,158 GDP (PPP) as share (%) of world total: 0.47Institution Responsible for HEPA:

Swedish Sports Confederationwww.rf.seTwitter account: @RFidrottenPer capita government expenditure on health at average exchange rate 2011 (US$):

4314.5

SwedenPopulation (millions): 7.9 GDP (US$ billions): 632.4 GDP per capita (US$): 79,033 GDP (PPP) as share (%) of world total: 0.44Institution Responsible for HEPA:

Swiss Federal Office for Sport (FOSPO) Federal Office for Public Health (FOPH)http://www.bag.admin.ch/index.html?lang=enhttp://www.baspo.admin.ch/internet/baspo/fr/home.htmlTwitter Account: @BAG_OFSP_UFSP (for FOPH; no official account for FOSPO)Per capita government expenditure on health at

average exchange rate 2011 (US$): 5966.5

Switzerland

Population (millions): 22.3 GDP (US$ billions): 1,541.8 GDP per capita (US$): 67,723

GDP (PPP) as share (%) of world total: 1.17Institution Responsible for HEPA:

Australian Sports Commission, part of the Department of Health (ASC) http://www.ausport.gov.au, http://www.health.gov.auTwitter account: @Ausport, @HealthgovauPer capita government expenditure on health at

average exchange rate 2011 (US$): 4068.8

Australia

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In terms of the relevant institution with competency for HEPA promotion in Switzerland, we will note that while sports policy is the remit of the Swiss Federal Office for Sport (FOSPO), it collaborates closely with the Federal Office for Public Health (FOPH) when it comes to physical activity promotion. Both have included HEPA as key objectives in their strategies. We have referenced herewith (see References) the relevant literature and the policy documents of these institutions (c.f. Schöppe et al. 2004, p. 40-46; Stamm et al. 2013; PNAAP National Plan 2008 and Review 2013; FOSPO Concept for National Policy; FOPH Santé 2020 Strategy). It is not our goal to provide an analysis of the Swiss sport and physical activity promotion policy, but rather draw out some relevant and interesting ideas from the 5 country profiles described in this study, which may be applicable to Switzerland. 7 best practices are presented below: An Integrated Multistakeholder Approach; Cross-Disciplinary Action; Comprehensive Data Collection; Improved Access to Information; Innovative Marketing and Communication; Engaging Branding; and Impact Assessment and Trends.

An Integrated Multistakeholder Approach

Our research has put forward a number of ideas on how to achieve collaboration at several levels of Government administration. The Australian approach on the one hand delineates clear spheres of regional authority to implement a number of more local measures. The Swedish model on the other hand has a distinct separation of roles between institutions, with the Government “outsourcing” some of the

traditional ministerial roles and responsibilities to other institutions. Both systems work using a clear definition of the scope of each actor’s role and responsibility and the use of collaborative approaches for knowledge sharing. These include online databases, intranet, and other virtual tools, all of which promote efficiency, reduce internal barriers to communication and ensure transparency. Both the Australian and Swedish policies also reference the need to involve other actors such as NGOs, private companies, healthcare providers, clubs and associations, in order for policies to truly have a multistakeholder dimension.

Cross-Disciplinary Action

Collaboration with other sectors, such as linking physical activity to nutrition and well being, was also referenced in many of the strategies examined. France’s PNNS in particular outlined a dual approach between physical activity and nutrition to achieve healthier lifestyles. There are other areas to involve as well (see for example on sustainable urban mobility http://www.epomm.eu/endurance/index.php). “To develop supportive environments it is necessary that policy interventions move beyond the health and sports sector, and integrate other sectors such as recreation, education, transport, urban safety as well as urban planning and environment, placed within governmental as well as non governmental organisations, and in the private sector. Strategic intersectoral planning and action within these sectors is essential to create broad physical activity policies” (Schöppe et al. 2004, p. 9). Some suggestions are summarised in Figure 9. Cross-disciplinary collaboration

FIGURE 9: Comprehensive Physical Activity Policies (Schöppe et al. 2004, p. 9)

Individual-oriented interventions

• Comprehensive community-wide campaigns including mass media strategies as well as social support, risk factor screening, setting-oriented counselling/ education and community events

• Point-of decision prompts to encourage stair use

• Structured physical activity programs targeted to specific groups (e.g. school-based physical education, individually-adapted health behaviour change programs, social support interventions in community settings)

• Physical activity services

Environmental interventions

• Provision of parks, recreation areas, attractive footpaths, walking/jogging trails, cycling paths, appropriate stairways in public buildings, road safety, active transportation

• Development of indoor/outdoor exercise facilities

• Provision of showers and change rooms at workplace

• Connection of homes with shopping areas

• Provision of secure parking for bicycles, bike carriers on buses

• Reduction of insurance rates for active and fit employees

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may also be the answer to better targeting particular population groups with specific messages (see in particular 7 Investments That Work for Physical Activity, http://www.globalpa.org.uk/investments/).

Comprehensive Data Collection

The need for up-to-date and detailed data on habits and practices in the population was mentioned several times in the policies analysed, and undertaken by most countries in the shape of a national physical activity survey. We saw this to be notably implemented in Australia with the ERASS (http://www.ausport.gov.au/information/casro/ERASS), the UK with the Active People Survey (http://www.sportengland.org/research/who-plays-sport/) and France with the Health and Nutrition Barometer (http://www.inpes.sante.fr/Barometres/index.asp). We can also cite a best practice from Switzerland, which has its own Nutrition and Physical Activity Monitoring System (MOSEB) to track 51 nutrition and physical activity related indicators throughout the Swiss population (www.moseb.ch), with a comprehensive break-down available per indicator.

Improved Access to Information

Extracting the relevant information from survey results could be facilitated, as we found a large variation in the accessibility and ease of navigation of online information. All of the countries analysed provided their documents and survey results as PDFs downloadable from the website of the relevant institution. However, only one of them packaged this information in a searchable, interactive format complete with infographics or links to videos, other material and relevant studies, etc. A best practice here is therefore the Sport England Active People

Survey Analysis Tool (http://activepeople.sportengland.org). It is a fully interactive online platform that enables navigation of the survey data in a tailor-made fashion based on the interests of the viewer. A short video describes how to use the dashboard and consult the desired analysis display based on regions, measures, demographics, and so on. These can then be exported as charts, tables, maps or spreadsheets for further analysis and use by the general public or local policy-makers.

Innovative Marketing and Communication

In terms of means of communication of information, the ministries of Australia, France and the UK and the Swedish Sports Confederation have a presence on Twitter and/or other social media, which they use to vehicle different messages about their current undertakings or introduce new projects. Informally, our personal following of these accounts showed the Australian Sports Commission to be particularly active on its Twitter Account. The French Minister for Health @MarisolTouraine has the most followers at 41,495; and @Sport_England the most tweets at 8697 (figures from December 2013). The level of interactions on the topic of physical activity would warrant further analysis, but the point is that digital media may represent a unique opportunity to better market and communicate the work of government institutions more broadly and sports and health promotion in particular. Besides Twitter, websites are the first go-to place in this context and here we would cite http://www.sportengland.org and http://www.mangerbouger.fr as standing out from the sites researched in the context of this study. They are visually compelling, interesting and easy to navigate, and full of interactive content (videos, photos, graphs, maps, etc.).

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Engaging Branding

An open question remains about how best to communicate the notion that exercise has a number of health benefits. For example, the policy documents sometimes used a number of terms interchangeably: physical activity, sport, HEPA, exercise, movement, motion. Australia used its own definition and consistently referred to “sport and active recreation” throughout its policy material. Another case to point in terms of messaging is that the literature used in our research on the benefits of regular physical activity always referenced HEPA as a preventive method to help from developing diabetes, cancer, heart disease, osteoporosis, etc. later on in life. Most of the policy documents also made reference to NCDs and the related WHO figures up-front. But what of other benefits, such as improved academic performance (see notably http://sparkinglife.org), some of which may be more immediate than the longer term benefits of keeping NCDs at bay? Positive messaging combined with simple, creative branding may be effective means of communicating existing policy work of which there is perhaps currently little awareness.

Impact Assessment and Trends

To measure progress on objectives, several of the policies we analysed suggested establishing processes and commissioning studies on impact assessment. These were often outsourced to an independent auditor, as was the case in Australia for the assessment of the AASC programme (see Figure 3). In practice, however, there is often little evidence of what results the various policy measures are having in changing behaviours and decreasing rates of inactivity. Studies show that it would

appear “some countries may have been successful in tackling the problem of physical inactivity through physical activity policies. But present data on national trends in physical activity is rare, and there are diverse methodological approaches for measuring physical activity and data collection across countries… It is difficult to compare population levels of physical activity between countries and to identify international trends. The currently conducted International Physical Activity Survey addresses this issue by assessing population levels of physical activity in several countries using an uniform instrument (International Physical Activity Questionnaire, IPAQ)” (Schöppe et al. 2004, p. 64-65). However, our research also found that this instrument has varying degrees of accuracy and several studies proved it to be inconclusive. “Insufficient approaches exist in terms of process evaluation and monitoring of physical activity policies… There is a lack of role delineation and accountability among partners, and an apparent failure to determine concrete timeframes related to the funding and implementation of single strategies” (Schöppe et al. 2004, p. 2). Reference to an external set of concrete recommendations may be useful in providing a more tangible set of targets for monitoring and evaluation, such as the WHO Global Recommendations on Physical Activity for Health (see Figure 1) or Key Points for Policy-Makers (see Figure 10).

B E S T P R A C T I C E S

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C O N C L U S I O N

FIGURE 10: Ten Key Points for Policy-Makers (WHO 2011, p. 48-49)

1. There is a great opportunity for the health and sport sectors to work together to promote health-enhancing physical activity and Sport for All. Cooperation can be particularly advantageous in areas such as activating disadvantaged groups, the elderly and people with low physical activity levels, and combating inequalities in participation in sport and physical activity. Sport can play a crucial role in the prevention of NCDs.

2. Intersectoral collaboration is an important element of successful sport and physical activity promotion strategies, and addressing this aspect more specifically with regard to implementation could further increase the impact of policies.

3. The promotion of sport and physical activity is relevant to many different sectors. It is therefore important to include all stakeholders in a consultation process to support coordinated efforts to promote sport and public health across different sectors and to capitalize on synergies with other public health efforts.

4. Collaboration should take place not only among ministries but also across government levels (national, regional and local), with civil society and the voluntary and private sectors.

5. Local environments have a crucial role in promoting sport and physical activity, since it is mainly in the local setting that the opportunities to be physically active are provided.

6. Taking a life course approach and offering physical activity in different settings, including schools and work places, is essential to the promotion of sport and physical activity.

7. Targets should be specific, measurable, achievable, realistic and time-bound (SMART) and different subgroups of the population need to be addressed by specific targets and actions related to the promotion of sport and health-enhancing physical activity.

8. An overview of financial resources to implement and monitor the sport and physical activity policies should be provided to ensure the allocation of resources and to create a solid basis for action.

9. Elite sports facilities should not be prioritized at the expense of facilities for the general public and the planning of recreational sports facilities should be considered as an integral part of urban planning.

10. Process and outcome evaluation should always be a planned and integrated part of sport and physical activity policies in order to assess whether goals are reached and if possible how they are reached and to assess whether allocated resources are effectively used.

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Diversity

This study has shown that there is great variety in the approaches to sport and physical activity promotion in national policy. Some countries have made this the responsibility and even the raison d’être of their national sports movement (the UK, Hungary, Sweden), while others have kept this an explicit part of their public health strategy (France), and there are cases where the two overlap (Australia).

Complementarity

There exists a large degree of complementarity between the sports and health sector in the work that they do to promote the public getting active more broadly. By conducting a literature and policy review with an in-depth focus on a selection of case studies, we were able to highlight some interesting undertakings as well as gaps in the practice of other countries, and by extension suggest more broadly which are the strategies that may prove to be useful in implementing such programmes.

Implementation

The development of tools and guidelines to assist the implementation of HEPA policies must go hand-in-hand with the elaboration of indicators to monitor progress, gauge results and measure impact, in response to specific national demands and contexts as a priority, but ideally also allowing for international comparison. In a recent study looking at sports for health promotion strategies in the EU, the WHO suggested 10 elements that are imperative to consider; they are listed in the box in Figure 10 and corroborate with many of the findings of the present analysis.

C O N C L U S I O N

“Policies are not self-implementing” (Salvesen et al. 2008, p. 280)

CONCLUSION

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Based on the analysis of this report, we would sum up the key elements to consider for achieving success in national sport and physical activity for health promotion work as a short framework, which we have coined the “5 Cs of Sport for Health Promotion”: Capacity, Consultation, Coordination, Communication, Commitment.

C O N C L U S I O N

FIGURE 11: 5 Cs of Sport for Health Promotion

refers to continuing the consultation of relevant stakeholders as well as openly communicating with the actors in the system in order to avoid double work, ensure efficiency, and guarantee timely delivery of project goals.

Coordination

has to do with ensuring all the relevant parties with a stake in the project have been able to contribute their thoughts and views, and that these have been factored into the design of new policies.

Consultation

5 Cs

means budgeting and making space for the best expertise to have access to the latest knowledge and enable structures to be set up to implement, monitor and evaluate progress.

Capacity

requires the clear definition of roles and responsibilities and the creation of channels of accountability for all parties. It also refers to SMART (specific, mea-surable, attainable, realistic and timely) target setting for impact assessment and continuous monitoring of the latest data.

Commitment

is the key factor for breaking down silos throughout the process, but also involving the general public and an international audience of experts, practitioners, and policy-makers.

Communication

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Australia. Department of Health. Health and Ageing Portfolio Budget Statements. 2011.

Australia. Sport and Recreation Ministers’ Council. National Sport and Active Recreation Policy Framework. 2011.

Australia. Australian Sports Commission. Active After-School Communities (AASC) Programme: Helping Children and Communities Get Active. 2012.

Australia. Australian Sports Commission. Annual Operational Plan 2011-2012. 2011.

Australia. Australian Sports Commission. Exercise, Recreation and Sport Survey (ERASS) Methodology Report. 2010.

Bellew, Bill, et al. “Public Policy Actions Needed to Promote Physical Activity”, Current Cardiovascular Risk Reports 5 (2011): 340-349.

Bornstein, Daniel Benjamin, et al. “A Review of the National Physical Activity Plans of Six Countries”, Journal of Physical Activity and Health 6(2) (2009): 245-264.

Bull, Fiona C., et al., “Implementing national population based action on physical activity- for action and opportunities for international collaboration”, Promotion & Education 13 (2006): 127-132.

Cavill, Nick, et al., British Heart Foundation Health Promotion Research Group. “Improving Health Through Participation in Sport: A Review of Research and Practice”. Department of Public Health, University of Oxford 2012.

Daugbjerg, Signe B., et al., “Promotion of Physical Activity in the European Region: Content Analysis of 27 National Policy Documents”, Journal of Physical Activity and Health, 6 (2009): 805-817.

Escalon H., et al., Baromètre santé nutrition 2008. Saint-Denis: 2009.

European Commission (EC). Directorate-General for Competition. Supporting the Hungarian sport sector via tax benefit scheme. (C(2011)7287 final) Brussels: 2011.

EU Working Group Sport and Health. EU Physical Activity Guidelines: Recommended Policy Actions in Support of Health-Enhancing Physical Activity. Brussels: 2008.

France. Ministry of Health. French National Nutrition and Health Programme (PNNS) 2011-2015. Paris: 2010.

Global Advocacy for Physical Activity (GAPA) the Advocacy Council of the International Society for Physical Activity and Health (ISPAH). “NCD Prevention: Investments that Work for Physical Activity”, February 2011 <http://www.globalpa.org.uk/investments/>

Hungary. National Institute for Health Development (NIHD). Department of Life-style. Programs on Healthy Nutrition and on Sustaining and Restoring the Energy Balance (balance between nutrition and exercise). 2011.

Lyons, Ronan A., et al. “Use of data linkage to measure the population health effect of non-health-care interventions”, The Lancet, 29 November 2013 <http://dx.doi.org/10.1016/S0140-6736(13)61750-X>

Newspoll, Evaluation of the AASC Programme 2009/10 - Programme Monitoring (Wave 2) Final Report. 2011.

Salvesen, David, et al., “Factors Influencing Implementation of Local Policies to Promote Physical Activity: A Case Study of Montgomery County, Maryland”, Journal of Public Health Management and Practice 14(3) (2008): 280-288.

Schöppe, Stéphanie, et al., “International Review of National Physical Activity Policy: A Literature Review”, Report No. CPAH04-0002, New South Wales Centre for Physical Activity and Health, 2004.

Stamm, Hanspeter, et al., “Analyse des projets de monitorage dans le domaine de l’alimentation et de l’activité physique en Suisse”, Lamprecht and Stam Social Research and Consulting Ltd., Zurich: 2008.

Stamm, Hanspeter, et al., “Die Förderung gesundheitswirksamer Bewegung und der Kampf gegen die Inaktivität: Situationsanalyse und Definition der Rolle des Bundesamtes für Gesundheit”, Lamprecht and Stam Social Research and Consulting Ltd., Zurich: 2013.

Sweden. Government Bill 2008/09:126. Statens stöd till idrotten. Stockholm: 2009.

Swedish Professional Associations for Physical Activity (Yrkesföreningar för Fysisk Aktivitet). Physical Activity in the Prevention and Treatment of Disease. 2010.

Swedish Sports Confederation (Riksidrottsförbundet). Idrott hela livet: strategisk plan för idrottsrörelsens folkhälsoarbete. Stockholm: 2008.

R E F E R E N C E S

REFERENCES

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Switzerland. Federal Department of Home Affairs (FDHA). Santé 2020: Politique de la santé: les priorités du Conseil fédéral. Bern: 2013.

Switzerland. Federal Office for Public Health (FOPH). Programme national alimentation et activité physique (PNAAP) 2008 – 2012. Bern: 2008.

Switzerland. Federal Office for Public Health (FOPH). Programme national alimentation et activité physique (PNAAP): Rapport 2008 – 2012. Bern: 2013.

Switzerland. Federal Office for Sport (FOSPO). Concept du Conseil fédéral pour une politique du sport en Suisse (“spoco”): Rapport sur les mesures d’application de 2003 a 2006. Macolin: 2006.

Switzerland. Federal Office for Sport (FOSPO). The Swiss Federal Government’s Concept for a National Sports Policy. Macolin: 2000.

United Kingdom. Department for Culture, Media and Sport (DCMS). Creating a sporting habit for life. 2012.

United Kingdom. Department for Culture, Media and Sport (DCMS) and Sport England. Measurement Consultation Summary of Responses. 2013.

Weiler R., et al. “Is the lack of physical activity strategy for children complicit mass child neglect?”, British Journal of Sports Medicine, 16 December 2013 <http://bjsm.bmj.com/content/early/2013/11/27/bjsports-2013-093018.full.html>

World Economic Forum. The Global Competitiveness Report 2013–2014: Full Data Edition. Geneva: 2013.

World Health Organization (WHO). Global Recommendations on Physical Activity for Health. Geneva: 2010.

World Health Organization (WHO). WHO Regional Office for Europe. Promoting Sport and Enhancing Health in European Union Countries: a Policy Content Analysis to Support Action. Copenhagen: 2011.

Attended the 6th National Meeting of the HEPA Networks, 20.11.13, Macolin, Switzerland.

R E F E R E N C E S

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W E B L I O G R A P H Y

WEBLIOGRAPHYAgita Mundo World Day for Physical Activity http://www.portalagita.org.br/en/agita-mundo/world-day-for-physical-activity.html

Australian Government Department of Health http://www.health.gov.au Twitter Account: @healthgovau https://twitter.com/healthgovau

Minister for Health and Minister for Sport: Peter Dutton Twitter Account: @PeterDutton_MP https://twitter.com/PeterDutton_MP

Australian Exercise, Recreation and Sport Survey (ERASS) http://www.ausport.gov.au/information/casro/ERASS

Australian Sports Commission and Australian Institute of Sport http://www.ausport.gov.au Twitter Accounts: @Ausport https://twitter.com/Ausport

Hungarian Ministry of National Resources http://www.nefmi.gov.hu/english

Hungarian National Institute for Health Development http://www.oefi.hu/aboutus.htm

French Ministry of Social Affairs and Health http://www.sante.gouv.fr Twitter Accounts: @Minist_Social https://twitter.com/Minist_Social

Minister of Social Affairs and Health: Marisol Touraine Twitter Account: @MarisolTouraine https://twitter.com/MarisolTouraine

French Ministry of Sport, Youth, Popular Education and Community Life http://www.sports.gouv.fr Twitter Accounts: @Sports_gouv https://twitter.com/Sports_gouv

Minister of Sport, Youth, Popular Education and Community Life: Valérie Fourneyron Twitter Account: @vfourneyron https://twitter.com/vfourneyron

French National Institute of Health Prevention and Education http://www.inpes.sante.fr/default.asp

French National Nutrition Programme PNNS http://www.mangerbouger.fr

Global Physical Activity Network (GlobalPANet) http://www.globalpanet.com

International Physical Activity Questionnaire (IPAQ) https://sites.google.com/site/theipaq/

Move, Eat, Treat http://www.moveeattreat.org Twitter Account: @MoveEatTreat https://twitter.com/MoveEatTreat

Nutrition and Physical Activity Monitoring System (MOSEB) http://www.moseb.ch

Sparking Life: Power Your Brain Through Exercise http://sparkinglife.org/page/home

Sport England (The English Sports Council) http://www.sportengland.org Twitter Account: @Sport_England https://twitter.com/Sport_England

Sweden Ministry of Culture Sports Section http://www.government.se/sb/d/9352

Swedish Professional Associations for Physical Activity http://www.fyss.se/fyss-in-english/

Swedish Sports Confederation (Riksidrottsförbundet) http://www.rf.se Twitter Account: @RFidrotten https://twitter.com/RFidrotten

Swiss Federal Office of Public Health (FOPH) http://www.bag.admin.ch/index.html?lang=en Twitter Account: @BAG_OFSP_UFSP https://twitter.com/BAG_OFSP_UFSP

Swiss Federal Office for Sport (FOSPO) http://www.baspo.admin.ch/internet/baspo/fr/home.html

UK Institute of Sport Exercise and Health (ISEH) http://www.iseh.co.uk/welcometoISEH

WHO Global Health Observatory Data Repository http://apps.who.int/gho/data/view.main.1920ALL?lang=en

WHO NCD Surveillance Strategy http://www.who.int/ncd_surveillance/strategy/en/

WHO Regional Office for Europe Health Topics: Physical Activityhttp://www.euro.who.int/en/health-topics/disease-prevention/physical-activity

31

I would like to extend my thanks to the following persons for their input and guidance throughout the research for this study:

Tania Dussey-CavassiniVice-Director General, Ambassador for Global Health

Head of Division of International AffairsFederal Office of Public Health FOPH

Dr. Boris GojanovicHead of Sports Medicine

Swiss Olympic Medical CenterSwiss Federal Institute for Sports FOSPO

Gisèle Jungo Senior Officer in charge of Political Affairs

and the Promotion of Physical Activity Division of National Prevention Programmes

Section for Nutrition and Physical Activity Federal Office of Public Health FOPH

And for the layout and graphic design:

Iva Stastny Brosig DESIGN [+]

www.designplus.hr

Viktoria Ivarsson is a recent graduate of the 2013 MSA (Master of Advanced Studies) in Sports Administration and Technology, at the EPFL in Lausanne. Previously, she worked at the World Economic Forum in Geneva for almost 6 years.

As Senior Manager for Academic Networks, she coordinated the Forum’s relationships with universities and other academic institutions and managed a group of eminent experts working on the topic of the Future of Universities. Prior to this, she was with the Forum’s Global Redesign Initiative, supporting the Forum’s Vice-Chairman, Lord Malloch-Brown. She has worked on several other strategic projects of the Forum, and is a contributor to the Global Risk Report 2008, 2009 and 2010 editions. In those same years she was Executive Assistant to Klaus Schwab during the Annual Meeting in Davos. Of Swiss and Swedish nationality and fluent in four languages, she has a MA in International Relations from the Graduate Institute of International Studies in Geneva and a Certificate in International Polish Studies from Jagiellonian University in Kraków, Poland.

Her current research interests include the use of sport in development; patterns in sport participation and social class; sport for health promotion; and the use of social media by international organisations. She can be followed on Twitter at V_Ivarsson (https://twitter.com/V_Ivarsson).