National policies on physical activity from 64 countries with different economies: a scoping review with thematic analysis

Abstract

In 2018, the World Health Organization (WHO) launched a Global Action Plan on Physical Activity (PA), which included 20 policy actions for creating active societies, environments, people and systems. The objective of this scoping review was to summarize the themes/contents of national PA policies/plans conforming to the WHO’s proposals and the country’s economy. This review followed Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews. A systematic search of electronic databases (Web of Science, Medline/PubMed, LILACS, PsycINFO, Scopus and SPORTDiscus) and 441 government documents/websites from 215 countries/territories was conducted (February 2021). Documents on national-level policies, published in English, Spanish and Portuguese since 2000, were eligible. The information on content and structure was systematically extracted and summarized into dimensions proposed by the WHO: active societies, environments, people and systems. The search identified 888 article references and 586 potentially relevant documents. After the screening, 84 policy documents from 64 countries were eligible. Most documents (n = 46) provided detailed PA policies/plans amid other health topics (e.g. non-communicable diseases, named ‘general documents’), and 38 were PA-specific. The content analysis merged 54 visions, 65 missions, 108 principles, 119 objectives, 53 priorities, 105 targets, 126 indicators and 1780 actions/strategies from 38 PA-specific and 46 general documents. Among the PA-specific documents, the active system’s dimension was the most contemplated in the principles (n = 43), priorities (n = 51) and action/strategies (n = 530) elements. At the same time, the objectives (n = 39), targets (n = 52) and indicators (n = 58) presented contents more frequently related to the active people dimension. For the general documents, all principles (n = 4), objectives (n = 14) and priorities (n = 7) were related to the dimension of active people, while target (n = 51), indicator (n = 53) and actions/strategies (n = 292) elements presented content related to all dimensions. The increase in countries with national PA policies/plans should be followed by improving the current ones because important dimensions seem to be not considered in these documents. This will facilitate a global PA agenda that considers the complexity and multidimensionality of PA promotion.

Introduction

Increasing physical activity (PA) in the population is relevant for many reasons. First, ∼7.2 and 7.6% of all-cause and cardiovascular disease deaths can be avoided with PA (Katzmarzyk et al., 2022). Second, an active population can decrease costs arising from care at the secondary and tertiary levels of health care due to factors that could be avoided through a physically active lifestyle (Ranasinghe et al., 2021). In contrast, physically active people are associated with increasing productivity, leading to substantial economic gains for the global economy (Hafner et al., 2020). Therefore, it is fundamental to have public policies, plans and national and international actions to encourage a more active population (World Health Organization, 2018).

PA has been a part of the World Health Organization (WHO)’s agenda for the past five decades (Vuori, 2018), which was reinforced in 2020 with the update of WHO’s guidelines on PA (Bull et al., 2020). In 2004, the WHO launched a Global Strategy on Diet, Physical Activity and Health, and its overall goal was to promote and protect health through healthy eating and PA (World Health Organization, 2004). In 2018, the WHO launched a Global Action Plan on PA, inviting countries to implement policy actions for a 15% reduction in physical inactivity level by 2030 (World Health Organization, 2018). Hence, countries were called up to develop PA policies based on the WHO’s framework elements (e.g. vision, mission, goals, principles, objectives and strategies), which proposed 20 policy actions organized into objectives for active societies (social norms and attitudes), environments (spaces and places), people (programs and opportunities) and systems (governance and facilitators) (World Health Organization, 2018).

It is expected that successful public policies will be able to reduce health inequities faced by minority groups (e.g. gender, ethnicity and disability), considering the different socioeconomic conditions of countries (Moorthie et al., 2022; Pan American Health Organization, 2022). For example, people residing in less favoured areas are less likely to have access to leisure facilities, education, sanitation and medical care (World Health Organization, 2019a; McGowan et al., 2021). Therefore, the combination of government policies can support the reduction of health inequities (Barsanti et al., 2017; Thomson et al., 2018).

A survey of 76 countries revealed that most countries have a PA policy (92%); guidelines, surveillance or monitoring systems (62%) and PA goals (52%) (Klepac Pogrmilovic et al., 2020). However, their PA policies’ levels of coverage, implementation and effectiveness are considered low to moderate, as most are developed in high-income countries (HICs) (Klepac Pogrmilovic et al., 2020). Previous reviews have also summarized information on PA policies in European countries (Daugbjerg et al., 2009; Bull et al., 2015), in schools (Nathan et al., 2018; Woods et al., 2021) or in different action contexts (Klepac Pogrmilovic et al., 2018; Gelius et al., 2020; Racine et al., 2020). For instance, Klepac Pogrmilovic et al. (2018) performed a scoping review to map the evidence regarding the indicators, development and descriptive content of PA policies worldwide. However, the authors did not perform an in-depth content analysis of the policies (e.g. actions, activities and strategies). Moreover, previous reviews have not evaluated the themes/contents that emerged from national PA policies’ principal components (e.g. objectives, actions and indicators). Therefore, it is not possible to identify the main elements (e.g. vision, mission, principle, objectives, priority, targets, indicator, actions, activities and strategies) that are addressed (and those that need to be addressed) in the scope of national policies on PA, especially in comparison to the objectives and actions proposed in the WHO’s Global Action Plan (World Health Organization, 2018). Moreover, an updated, systematic evidence synthesis should be performed to understand the content of national PA policies according to the income level of the countries since PA gains from a global health perspective might be greater when actions are implemented in upper middle-income countries (UMICs), lower middle-income countries (LMICs) and low-income countries (LICs) (Salvo et al., 2021). Thus, a synthesis that fills these gaps may help develop or improve current and future national policies on PA.

In this sense, we performed a scoping review to summarize the themes/contents of national policies on PA (or including PA) globally according to the elements and actions/strategies addressed in the WHO’s Global Action Plan on PA (World Health Organization, 2018) by countries’ income (HICs, UMICs, LMICs and LICs) (World Bank Country and Lending Groups, 2021).

Methods

The scoping review conducted in this study (registered in Open Science Framework, https://osf.io/9frbn/) addresses national policies focused on promoting PA worldwide to identify knowledge gaps and key concepts (Colquhoun et al., 2014), defines research agendas, identifies implications and helps in decision-making (Tricco et al., 2018). The methodological procedure was carried out in five steps: (1) identification of the research question, (2) identification of relevant studies, (3) study selection, (4) data mapping and (5) grouping, summarizing and reporting of the results (Arksey and O’Malley, 2005). Furthermore, the ‘Joanna Briggs Institute’ (Peters et al., 2020) manual was considered for the methodological decisions in this review and the PRISMA extension for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018) (Electronic Supplementary Material 1) guided the reporting.

Research question and selection criteria

This review aimed to answer the following question: ‘Which and how are the dimensions from the WHO’s proposals (active societies, environments, people and systems) covered in the elements (e.g. vision, mission, goals, principles, objectives, indicators and actions/strategies) of national PA policies/plans from countries of different economies?’ The eligibility elements and criteria are presented in Table 1.

The details of applying these eight exclusion criteria are shown in Figure 1.

Identification of relevant studies

Electronic searches were performed on six databases/electronic scientific repositories (Web of Science, Medline/PubMed, LILACS, PsycINFO, Scopus and SPORTDiscus) from February 9 to 21, 2021 (Electronic Supplementary Material 2). In addition, 441 government websites and document databases from 215 countries/territories were screened to find relevant documents (grey literature) from January to March 2021. Additional searches were carried out by reviewing references on the theme (Daugbjerg et al., 2009; Bull et al., 2014; 2015; Rütten et al., 2016; Klepac Pogrmilovic et al., 2018; 2019b; 2020; Ramirez Varela et al., 2018; Racine et al., 2020) and researchers’ library, screening references of included studies and contacting the authors.

Database searches were performed using terms obtained from previous literature (Klepac Pogrmilovic et al., 2018; 2019b; 2020; Ramirez Varela et al., 2018; Racine et al., 2020) and were structured according to the Medical Subject Headings. Boolean operators (OR, AND and NOT) and truncation symbols were used (Electronic Supplementary Material 2). After the search, the titles were imported into an EndNote Web software library, and duplicates were manually excluded using the reference manager functions.

Study selection

Three evaluators carried out the selection process, which involved two phases: (1) reading titles and abstracts and (2) reading full documents. A third researcher was consulted in case of disagreement between evaluators for each step. All evaluators had accumulated experience in previously published systematic reviews.

Data mapping

According to their focus, the documents were organized into two blocks: (1) ‘PA-specific’ policies/plans that addressed the promotion of only PA or combined with healthy eating, e.g. and (2) ‘general documents’ where PA was not considered a primary objective but a strategy to reduce and/or prevent diseases, such as the case of policies/plans aimed at fighting non-communicable diseases (NCDs). The documents were organized according to the country’s economic income level (World Bank Country and Lending Groups, 2021). In particular, the following release was published: ‘Venezuela was temporarily unclassified in July 2021, awaiting the release of revised national accounts statistics’ (World Bank Country and Lending Groups, 2021). Thus, in this document, the data for that country were kept in the income range of the previous consult (HIC). The countries were arranged alphabetically within each income level.

Data extraction was performed by a researcher and was reviewed by a second researcher. Only the data directly related to PA were extracted, even in the ‘general documents’ (e.g. strategies to improve eating behaviours were not extracted). The extracted elements were: (1) policy/plan description and identification variables (country, year, the focus of the document, referenced legislation, life cycles, sectors involved in preparing the policy, vision and mission); (2) central elements (principles and guidelines, objectives, priorities, goals and deadlines); (3) actions, activities and strategies and (4) contents regarding Comprehensive Analysis of Policy on PA (CAPPA) categories (monitoring and evaluation plan, deployment plan, financial support and results achieved) (Klepac Pogrmilovic et al., 2019a).

The data were extracted while maintaining the original content of the documents. However, when the goals related to PA were not presented in a specific document section, they were extracted from other sections, e.g. from the objectives. In this case, the information was presented in duplicate, as goal and objective. A thematic synthesis was conducted considering the multidimensionality and complexity of the extracted content and scope involving national PA policies. This dynamic and deductive–inductive process is essential for synthesizing evidence on complex issues (Fereday and Muir-Cochrane, 2006). To this end, the organization process and content categorization were carried out during the extraction by one of the authors and validated in consensus meetings between the authors to ensure that the topics found were correctly grouped and categorized until the themes were theoretically saturated.

Grouping, summarizing and reporting of the results

After extraction, the information was organized based on the four dimensions proposed by the WHO (World Health Organization, 2018): (1) active societies, (2) active environments, (3) active people and (4) active systems (Electronic Supplementary Material 3). Briefly, the dimension (1) Active Societies refers to social rules and attitudes towards creating a paradigm shift in knowledge, understanding and appreciation of the benefits of PA; (2) Active Environments is a dimension focused on creating and maintaining spaces and places for the practice of regular PA; (3) Active People is a dimension directed at access to programs and opportunities for people to engage in regular PA in various contexts and the dimension (d) Active Systems involves the various sectors of governance and facilitators to achieve excellence in mobilizing resources to implement coordinated international, national and local actions, aiming to increase the practice of PA.

The number of actions/strategies in each dimension and subcategories in the different income levels was counted (Salvo et al., 2021), as well as the content of each element according to the country’s income classification (in this case, the total can exceed 100% because some content was present in documents from countries with different income levels). Strategies that contained elements in more than one category within each dimension were grouped into ‘multicategories,’ and those that included elements from more than one dimension were allocated to ‘multidimension.’ The term ‘others’ was also used as a category in the dimensions to group the strategies that did not present repeated elements or left the message unclear.

Results

Among the 888 articles identified by the database, 34 articles and two references found in them were read in full, and only 1 met the eligibility criteria. Moreover, 586 documents were accessed (from 192 countries) on 441 government websites, of which 475 were read in full and 83 were included in this review. Thus, 84 documents (15 PA policies and 69 PA plans) from 64 countries (30 HICs, 20 UMICs, 13 LMICs and 1 LIC) were included in this review, of which 38 were ‘PA-specific’ and 46 were general documents that included PA (Electronic Supplementary Material 4 and Figure 1).

General features of documents

A total of 38 ‘PA-specific’ documents were included. PA was the sole focus in 13 documents, while others included themes such as sports (n = 10 documents), diet/food/nutrition (n = 6) and physical education and/or recreation (n = 5). Eleven documents mentioned the legislation/decree linked to the policy/plan, 33 were prepared for the entire life cycle and 13 were under the responsibility of the Ministry of Health or some Health Institute/Department (Table 2).

A total of 26 ‘PA-specific’ documents described the vision and mission of the policy/plan. The most frequently reported vision and mission, respectively, regardless of the country’s income level, was ‘to become a physically active and healthy nation’ and ‘to increase physical activity levels of the population, improving health and wellness’ (Electronic Supplementary Material 5, Table S1).

Of the 46 ‘general documents’ analysed, 38 focused on NCDs, 45 involved the general population, 13 referenced a legislation/decree linked to the policy/plan, 40 were under the responsibility of the Ministry/Institute of Health (Table 3), 30 reported the vision and 43 reported the mission (Electronic Supplementary Material 5, Table S2). Regardless of the country’s income level, the most present vision among the ‘general documents’ was ‘healthy communities, with people that live long, happy and purposeful lives’, and the mission was ‘to prevent NCDs and reduce risk factors, morbidity and mortality caused by NCDs’ (Electronic Supplementary Material 5, Table S2).

Principles, objectives, priorities, target and indicators

Figure 2a describes the relative quantity of elements (indicators, targets, priorities, objectives and principles) according to the type of document and the country’s income levels. The ‘PA-specific documents’ presented 117 principles, 114 objectives, 47 priorities, 71 targets and 81 indicators. The ‘general documents’ showed four principles, 14 objectives, 7 priorities, 51 targets and 53 indicators. In general, they were extracted from the documents of HICs and UMICs. No priorities were observed in the documents (‘PA-specific’ and ‘general’) from LMICs and LICs.

In the analysis of the elements by dimension (Figure 2b), ‘general documents’ addressed exclusively the active people dimension in priorities, objectives and principles; indicators and targets also addressed more frequently the active people dimension. In ‘PA-specific documents,’ all dimensions were addressed in the elements but in a disproportionate way: principles and priorities referred more to active societies and systems, and objectives, targets and indicators addressed more to the dimensions on active people and systems. The details are provided in Tables S1 (PA-specific) and S2 (general) and Electronic Supplementary Material 6.

We explored the content of each element according to the WHO´s dimensions and country’s income level (Figure 3). In the PA-specific documents, the principles (Figure 3a) mainly focused on the active societies and systems dimensions, independent of the country’s income level. For the objectives (Figure 3b), LMICs/LICs mainly centred on the active people dimension (67%), UMICs on the active systems (53%) and people (33%) and HICs on active people (39%), systems (25%) and societies (25%). Priorities (Figure 3c) were addressed exclusively in documents from HICs and addressed all dimensions. For targets (Figure 3d), active people were the most addressed dimension in all income levels; however, a substantial content for dimensions in active systems (39%) and active environments (30%) was also addressed in UMICs and LMICs/LICs, respectively. The indicators (Figure 3e) were directed towards the dimension of active people at all income levels.

In the ‘general documents,’ principles, objectives and priorities (Figure 3a–c, respectively) focused 100% on the active people dimension regardless of countries’ income. A large proportion of the content addressing the active people dimension was also observed for targets (from 80 to 89%, Figure 3d) and indicators (from 60 to 71%, Figure 3e) at all income levels. A detailed description of the themes and content that emerged in each dimension as indicators (Table S12), targets (Table S9), priorities (Table S6), objectives (Table S4) and principles (Table S2) can be found in Electronic Supplementary Material 6.

Actions, activities and strategies

A total of 1488 actions/strategies (85, 10 and 5% from HICs, UMICs and LMICs/LICs, respectively) was found in 33 ‘PA-specific’ documents. In general, the content was mostly directed towards the dimensions of active systems and people (Table 4). In the active systems dimension, strategies frequently included strengthening policies, plans, leadership and governance (n = 106), followed by developing innovative financial mechanisms (n = 68). The strategies with the highest frequency in the active people dimension were related to strengthening physical education as PA in school (n = 115), practicing sports as a promotion of PA (n = 61) and PA programs in other contexts (n = 66) (Table 4).

A total of 43 ‘general’ documents presented 292 actions/strategies (59, 20 and 21% from HICs, UMICs and LMICs/LICs, respectively) to promote PA (Table 5). The dimensions with the highest volume of content were active people and systems; strategies for active people mainly focused on the promotion of PA in the school (n = 22) and community (n = 26) contexts; strategies on active systems mainly focused on creating and implementing policies, plans, strategies, guidelines and legislation to promote PA (n = 46), and involving different organizations (e.g. private and public sectors) to increase the population’s PA (n = 21) (Table 5).

Implementation (actors, plan and financial support)

Twenty-three ‘PA-specific’ documents (18, 3 and 2 from HICs, UMICs and LMICs/LICs, respectively) mentioned the federal and state governments, institutions and general population as parties responsible for the implementation of PA policies/plans (Table S13, Electronic Supplementary Material 6). Four documents did not specify their implementation actors, and 11 mentioned only the federal government (n = 5) or one of the actors (n = 6). Furthermore, 33 documents contained information on the implementation plan, and only five documents (three from HICs and two from UMICs) contained information on financial support, and the amount and specifications varied by local currency (Table S13, Electronic Supplementary Material 6).

In the ‘general’ documents (Table S14, Electronic Supplementary Material 6), except for three documents that did not report the actors (two from HICs and one from UMIC), the federal government was also mentioned as responsible for implementing the document’s strategies. Other institutions and societies were also cited as actors with mutual responsibility for implementation. Most of them presented actions to be implemented, indicators, responsible sectors, and deadlines in their PA implementation plans. Ten documents contained information on financial support, and there was no standardization of values and currencies.

Policy/plan monitoring and evaluation

In ‘PA-specific’ documents, the monitoring and evaluation systems were specified in eight documents (five from HICs and three from UMICs) and all referred to their own systems. The frequency of evaluation varied among the documents, and there was no predominance of income level that contained such information (Table S13, Electronic Supplementary Material 6). In the ‘general documents’ (Table S14, Electronic Supplementary Material 6), the STEPwise approach to Surveillance and Global School-Based Student Health Survey―both surveys coordinated by the WHO―were reported. In addition, HICs also mentioned using national monitoring systems. Most documents from UMICs reported using the STEPwise survey over a period of 2–5 years. Sixteen documents (nine, three and three from HICs, UMICs and LMICs/LICs countries, respectively) did not report any information on the PA-related monitoring.

Discussion

This review systematically summarizes the themes/contents of national PA policies/plans from 64 countries from all income levels. We found 54 different visions, 65 missions, 121 principles, 128 objectives, 54 priorities, 122 targets, 134 indicators and 1780 actions/strategies that addressed the dimensions proposed by the WHO’s PA Global Action Plan (World Health Organization, 2018). In summary, we highlight the following findings: (1) ‘PA-specific’ policy/plans had a comprehensive content that addressed most of the elements and dimensions proposed by the WHO; (2) distinction among countries with different income levels was observed mainly because HIC has more ‘PA-specific’ documents and (3) most elements in the documents addressed themes related to the dimensions on active people and systems. These findings will help build and reformulate national PA policies/plans worldwide to attempt the complexity and multidimensionality of PA promotion, which is a pillar for a global health agenda (DiPietro et al., 2020).

The diversity in structure and content found in the documents may reflect the autonomy of each country in addressing the demands and priorities at the local, regional and national levels. This may explain why most documents focused on comprehensive health topics, such as health care and NCD policies, especially in LMICs/LICs. However, it appears that the ‘lack of information’ in general documents on different elements of the PA policy/plan makes it challenging to address content from all dimensions proposed by the WHO. For example, general documents on policy/plan did not provide sufficient information on any legislation linked to PA promotion (e.g. funding to PA strategies and programs in the national/regional laws).

The distinction among countries’ economies was consistent with the findings of a previous study (Klepac Pogrmilovic et al., 2020), which analysed data from 76 countries and revealed that quantifiable national targets for PA across countries are present in 52% (95% CI: 40–64%) of countries, and there are significant differences between country groups (P = 0.049) and world regions (P = 0.027) based on the income level. These findings reinforce the relevance and need for national PA policies/plans explicitly developed for this purpose (Klepac Pogrmilovic et al., 2018), especially for LMICs, where the prevalence of physical inactivity is also a public health problem (Guthold et al., 2018) and PA policies/plans are incipient. This will help in defining comprehensive policies/plans that address the multidimensionality of the PA behaviour (in different contexts, types and practices) and all dimensions needed to build active people and societies.

We found that most elements (especially indicators and targets) of the national PA policies/plans addressed themes related to the active people dimension; this pattern was observed in countries from all income levels. Most of them focused primarily on the elements of individuals’ behaviours and meeting guidelines on PA for health, which was relevant for the monitoring and surveillance of the health population (detailed in the supplementary materials Tables S8 and S10). However, it has a limitation in that PA promotion emphasizes indicators from an individual-based perspective (Bull et al., 2014; 2015; Health-enhancing physical activity (HEPA), 2015; Ramirez Varela et al., 2018; World Health Organization, 2018), which is contrary to the WHO’s proposal that the active people dimension should also focus on local, regional and national actions to create PA opportunities and programs in several contexts (physical education classes, health care and others) (World Health Organization, 2018), expanding the support PA opportunities for all populations.

Active societies and active environments were contextual dimensions less frequently addressed in PA policies/plans. This is a concern for PA policies/plans because they are needed to achieve a coordinated, whole-of-system response that can improve the social, cultural, economic and environmental factors that support PA (World Health Organization, 2018). That is, there is no isolated political solution. A systemic approach recognizes the interconnection and adaptive interplay of multiple influences on opportunities for PA. It allows showing the numerous opportunities for political action by different actors and partners to reverse the current trends of inactivity and how they interact at various levels (World Health Organization, 2018).

One of the most relevant results of this review was the large number and variety (>1000) of actions/activities/strategies that emerged from national PA policies/plans, focused mainly on the active people dimension. Among the possibilities, offering PA in the school environment (e.g. legitimization of physical education classes) has been considered a priority and ‘best-buy’ strategy to improve PA knowledge and behaviours in young people (Woods et al., 2021; Stylianou et al., 2022), being reinforced by the WHO’s Global Action Plan on PA 2018–2030 (World Health Organization, 2018). Similarly, several strategies/actions addressed the active system’s dimension as the creation and strength of leadership, multisector partnerships, advocacy and legislation. These actions are promisors for PA promoting at the population level because they contribute towards a meaningful community engagement and whole-of-system response to PA and reinforce multisectoral partnerships to achieve sustained change and impact (World Health Organization, 2018; Klepac Pogrmilovic et al., 2019a).

For active societies, two relevant actions emerged from several documents: implementation of social marketing campaigns and professional training. The first has been a relevant strategy in PA and health policies (King et al., 2018), which were in the spotlight during the coronavirus (COVID-19) outbreak (Farsi, 2021). The authors recommend that effective communication strategies in PA must consider key target audiences (including stakeholders, the general population and others) and their values, needs and preferences (Milton et al., 2020). Similarly, professional training strategies are crucial for increasing knowledge, skills and confidence in communication regarding PA benefits as well as for implementing supportive interventions, environments and opportunities for PA in different contexts (Milton et al., 2020). This is aligned with Astana Declaration on Primary Health Care, which emphasized that investment in education, training, development and motivation of the workforce is essential for a comprehensive, integrated, accessible and affordable health service, particularly in vulnerable areas and countries (World Health Organization, 2019b). According to McGowann et al. (2021), interventions to reduce inequalities must be implemented on a scale compatible with the level of disadvantage. For instance, content and specific action plans should incorporate specific beliefs or cultural norms.

The active environments addressed strategies to create and modernize environments available for the practice of leisure PA and develop urban transport systems and cities. This is aligned with robust evidence on how environmental changes affect the population’s health. For instance, Stevenson et al. (2016) found that changes in land use density/diversity, walking, cycling and public transport system could result in health gains in urban cities. Salvo et al. (2021) also simulated scenarios with multisectoral and multiple strategies to understand whether they affect PA promotion on a large scale and improve sustainable development goals. They found that contexts with investments in environmental and societies dimensions may improve PA and reduce air pollution and traffic-related deaths in cities, with expected gains being greater for LMICs/LICs. Thus, national PA policies/plans should be reformulated to clearly consider actions from this dimension.

Ideally, the WHO (World Health Organization, 2018) proposes that a PA policy should be followed by an action plan that identifies who does what, when, how and for how much (Health-enhancing physical activity (HEPA), 2015), according to country contexts and priorities. However, in the included documents, there was a wide variation in the description of the implementation plan, which made it difficult to understand the roles and actions of different actors and institutions in their specific jurisdictions, contexts and lives. Similarly, a survey of 150 PA- and sedentary-behaviour-specific policies found that 18 and 10% of them, respectively, had a low level of implementation or were not implemented at all, independent of the country’s income level and world region (Klepac Pogrmilovic et al., 2020). A poor description of the implementation plan is probably one of the reasons why strategies in national PA policies/plans have not been successfully implemented.

Regarding the monitoring and assessment of a PA policy/plan, there is no standardization regarding the form and/or the time interval to carry it out, contrary to what is recommended by the WHO (World Health Organization, 2018). Moreover, some documents stated that they would do so without specifying how it would be done. Another review including data from 76 countries found that 71% (95% CI: 60–81%) of them had a national health surveillance or monitoring system of PA (Klepac Pogrmilovic et al., 2020). In addition, in a content analysis of 27 national PA policies from 15 countries in the European region, quantified targets for PA were the exception, and population groups most in need, such as people with low levels of PA, were rarely specifically targeted (Daugbjerg et al., 2009). Different contexts between countries may require adjustments to the national target based on the global situation, either for countries that have not established targets in their plans/policies or for those that do not have a document aimed at promoting PA. However, the lack of a surveillance system to track the impact of their policy/plan on PA may not be able to assess their progress against the WHO 2030 target (Klepac Pogrmilovic et al., 2020).

Strengths and limitations

The key strengths of this review include the following: (1) the search was conducted through a range of bibliographic databases, reference lists of included articles and relevant websites, which reduced the likelihood of missing relevant publications in the selected languages; (2) a rigorous methodological process of study selection and thematic synthesis allowed us to identify and include relevant studies and extract a reliable and comprehensive content of the documents; (3) we conducted an in-depth analysis of the contents of the PA policies/plans for each specific country and according to the income level classification of the countries; and (4) the analysis of the contents of the PA policies/plans according to the dimensions of the WHO revealed inconsistencies in the structuring of the documents, with misaligned focuses in relation to what is desired, applied, measured and evaluated (DiPietro et al., 2020).

A possible limitation of this study is the restriction to documents published in English, Spanish and Portuguese; thus, we were not able to find and include documents in other languages (see excluded documents in Electronic Supplementary Material 4). In addition, we did not include in-depth search strategies, such as email or telephone contact with potentially relevant stakeholders and policymakers. We decided to keep with both methodological aspects because the translation process and in-death strategies have relevant time and financial costs, challenging a comprehensive evidence synthesis (Peters et al., 2020). This may also explain the low number of PA policies/plans from LMICs/LICs, an important limitation of the current body of evidence, as also observed in studies on PA policies (Klepac Pogrmilovic et al., 2018; Global Observatory for Physical Activity, 2021a; 2021b). Future reviews may expand search strategies to guarantee PA policies/plans from countries that had documents in native languages and that were not digitalized in electronic databases.

Practical and research implications

Furthermore, the practical and research implications of this scoping review may be considered to improve PA policies/plans at national and global levels as follows:

1. Considering the low number of PA-specific documents, especially from LMICs/LICs, governments and policymakers should work with national and international institutions and organizations on a global health agenda with a focus on working collaboratively to build national and PA-specific policies/plans, especially from LMIC/LIC economies.

2. Future national PA policies/plans should clearly describe all essential elements, such as principals, vision, mission, indicators and others recognized by the WHO (World Health Organization, 2018). This probably explains the large variety of content within the PA policy/plan found in our study and, sometimes, works in a divergent sense and makes scale-up implementation and evaluation difficult.

3. Countries that include a PA policy/plan within their health policies/plans may consider all dimensions from the WHO action plan to ensure homogeneity in the analysis of these documents.

4. Stakeholders and policymakers may consider strategies from different dimensions (e.g. PA opportunities and physical education in schools, multisector partnerships, advocacy, legislation, professional training and urban design), which were highlighted in this review, to enable inter- and intra-sectoral agendas for the development of viable actions in subpopulations and contexts.

5. Future research can focus on the dimensions that were less addressed in the PA policies/plans in the documents included in this review, mainly the active societies and environments dimensions. This may help understand the reason for less frequent consideration of these particular dimensions and to guide future policies by considering these elements (e.g. principles, objectives, indicators, targets and strategies) in national PA policies/plans.

6. Research may be performed to improve the indicators, targets and monitoring systems of PA policies, considering that we found a few PA policies/plans that detailed these elements. A comprehensive evaluation process, such as that proposed in the CAPPA conceptual system (Klepac Pogrmilovic et al., 2019a), is important for monitoring and evaluating the implementation of future PA policies/plans.

7. Research should evaluate which actions/activities/strategies are more effective in achieving the targets, considering the countries’ economic, social and cultural aspects, which has been considered a public health priority to advance the global PA agenda (DiPietro et al., 2020).

Conclusions

We found that 64 countries (30, 20, 13 and 1 of HICs, UMICs, LMICs and LIC, respectively) have national policies/plans that included specific content on PA promotion at the population level. This highlighted that, even in an incipient way, governments and policymakers from LMICs considered it important to build and implement PA policies in their countries. However, it should be followed by the improvement of current PA policies and an increase in the number of countries (especially LMICs/LICs) with PA-specific policies. This is relevant because important content (e.g. principles, objectives, priorities and action strategies) and dimensions (mainly of active societies and environmental dimensions) proposed by the WHO omitted or not considered in these documents. Our findings support a call for PA policies/plans in the global health agenda and may help build PA policies/plans that address the complex and multidimensional aspects of the PA promotion in countries without or with incipient national PA policies.

Supplementary data

Supplementary data is available at Heath Policy and Planning online.

Data availability

All necessary links or identifiers to our data are present in the main manuscript or supplementary materials.

Funding

This work was supported by the Pan American Health Organization, Regional Office for the Americas of the World Health Organization, Brazil (CON20-00017292). Individual grants from the Conselho Nacional de Desenvolvimento Científico e Tecnológico for V.C.B.F. (‘CNPq Productivity Grant’ process number: 312091/2021-4) and K.S.S. (‘Conselho Nacional de Desenvolvimento Científico e Tecnológico' (CNPq) Productivity Grant’ process number: 305803/2020-4). The views of the funding agency had no influence on the content or conduct of the review.

Acknowledgements

The authors thank 'Conselho Nacional de Desenvolvimento Científico e Tecnológico' (CNPq), Brazil, where K.S.S. and V.C.B.F. are National Council for Scientific and Technological Development Research Productivity Fellows (process numbers: 305803/2020-4 and 312091/2021-4). The views of the funding agency had no influence on the content or conduct of the review. The authors also thank 'Coordenação de Aperfeiçoamento de Pessoal de Nível Superior' (CAPES), Brazil, for the scholarships to A.S.B. from Higher Education Personnel Improvement Coordination (Finance Code 001).

Author contributions

G.M., K.S.S., P.F.S., S.W.M., J.R.M.S., R.C.M.P., and V.C.B.F. contributed to the conception of the article.

G.M., K.S.S., A.S.B., P.C.S., and V.C.B.F. were involved in the data collection.

G.M., K.S.S., A.S.B., P.C.S., P.F.S., S.W.M., and V.C.B.F. were involved in the data analysis and interpretation.

G.M., K.S.S., A.S.B., P.C.S., and V.C.B.F. drafted the article.

All the authors critically reviewed the article and provided the

final approval of the version to be submitted

Reflexivity statement

The authors include seven females and two males and span multiple levels of seniority. During the conduction of the study, four authors were part of the General Coordination for the Promotion of Physical Activity and Intersectoral Actions of the Ministry of Health of Brazil. At least five of the nine authors have extensive experience in conducting literature reviews and promoting physical activity through physical activity programs. The authors are distributed in three of the five regions of the country. The theme ‘promotion of physical activity’ is a research object of seven authors. We also consider inclusivity within the authors’ group as it encompasses the authors from different social roles, such as policymakers, managers and professors.

Ethical approval

Ethical approval for this type of study is not required by our institute.

Conflict of interest

None declared.

References