Journal of Physical Activity and Health, 2014, 11(Supp 1), S113-S125 http://dx.doi.org/10.1123/jpah.2014-0177 Official Journal of ISPAH © 2014 Human Kinetics, Inc. www.JPAH-Journal.com BRIEF REPORT Physical Activity of Children: A Global Matrix of Grades Comparing 15 Countries Mark S. Tremblay, Casey E. Gray, Kingsley Akinroye, Dierdre M. Harrington, Peter T. Katzmarzyk, Estelle V. Lambert, Jarmo Liukkonen, Ralph Maddison, Reginald T. Ocansey, Vincent O. Onywera, Antonio Prista, John J. Reilly, María del Pilar Rodríguez Martínez, Olga L. Sarmiento Duenas, Martyn Standage, and Grant Tomkinson The Active Healthy Kids Canada (AHKC) Report Card on Physical Activity for Children and Youth has been effective in powering the movement to get kids moving by influencing priorities, policies, and practice in Canada. The AHKC Report Card process was replicated in 14 additional countries from 5 continents using 9 common indicators (Overall Physical Activity, Organized Sport Participation, Active Play, Active Transportation, Sedentary Behavior, Family and Peers, School, Community and Built Environ- ment, and Government Strategies and Investments), a harmonized process and a standardized grading framework. The 15 Report Cards were presented at the Global Summit on the Physical Activity of Children in Toronto on May 20, 2014. The consolidated findings are summarized here in the form of a global matrix of grades. There is a large spread in grades across countries for most indicators. Countries that lead in certain indicators lag in others. Overall, the grades for indicators of physical activity (PA) around the world are low/poor. Many countries have insufficient information to assign a grade, particularly for the Active Play and Family and Peers indicators. Grades for Sedentary Behaviors are, in general, better in low income countries. The Community and Built Environment indicator received high grades in high income countries and notably lower grades in low income countries. There was a pattern of higher PA and lower sedentary behavior in countries reporting poorer infrastructure, and lower PA and higher seden- tary behavior in countries reporting better infrastructure, which presents an interesting paradox. Many surveillance and research gaps and weaknesses were apparent. International cooperation and cross-fertilization is encouraged to tackle existing challenges, understand underlying mechanisms, derive innovative solutions, and overcome the expanding childhood inactivity crisis. Keywords: active transportation, comparison, international, play, policy, sedentary behavior, sport The Active Healthy Kids Canada (AHKC) Report Card on In response to growing international concern over childhood Physical Activity for Children and Youth1,2 has been effective in physical inactivity, AHKC (www.activehealthykids.ca) hosted a powering the movement to get kids moving by influencing priori- Global Summit on the Physical Activity of Children in May of ties, policies, and practice in Canada.3 Details of the development 2014.8 The Summit brought together researchers, practitioners, of the AHKC Report Card and its impact have been previously policy-makers, and funders from the physical activity (PA), sport, described.1–5 The AHKC Report Card was designed to serve as a recreation, education, fitness, transportation, early childhood devel- knowledge translation instrument, aimed at increasing and accel- opment, public health, and medical sectors from across the globe. erating the dissemination of research, practice-based evidence and A highlight of the Summit was the presentation of Report Cards evidence-based practice through effective and strategic synthesis, from 15 countries,1,9–22 which were modeled after the AHKC Report exchange, mobilization, and application of knowledge while Card,1,2,4,5 adapted to each country’s local or specific context, and facilitating interactions among researchers and knowledge users.6,7 followed procedures that were harmonized with the Canadian pro- The AHKC Report Card has served as an advocacy mechanism cess.1,2 Details of the process in each country are briefly described to drive social action by stimulating debate, motivating policy, in this issue of the Journal of Physical Activity and Health.1,9–22 practice, and behavior modification and inspiring change in This paper consolidates findings from the 15 countries, creating Canada.1–3 a “global matrix” of common indicators graded by each country Tremblay (corresponding author: mtremblay@cheo.on.ca) and Gray are with Ghana. Onywera is with the Dept of Recreation Management and Exercise the Healthy Active Living and Obesity Research Group, Children’s Hospital Science, Kenyatta University, Nairobi, Kenya. Prista is with the Physical of Eastern Ontario Research Institute, Canada. Akinroye is with the Nigerian Activity & Health Research Group, Research Center on Sports Development Heart Foundation, Lagos, Nigeria. Harrington is with the Diabetes Research and Physical Activity, Universidade Pedagógica, Maputo, Mozambique. Reilly Centre, University of Leicester, Leicester General Hospital, United Kingdom. is with the Physical Activity for Health Group, School of Psychological Sci- Katzmarzyk is with the Pennington Biomedical Research Center, Baton Rouge, ences and Health, University of Strathclyde, Scotland. Rodríguez Martínez is LA. Lambert is with the MRC/UCT Research Unit for Exercise Science and with the Instituto Tecnológico de Estudios Superiores de Occidente (ITESO), Sports Medicine, Dept of Human Biology, Faculty of Health Sciences, Univer- Jalisco, México. Sarmiento Duenas is with the Dept of Public Health, School sity of Cape Town, South Africa. Liukkonen is with the Dept of Sport Sciences, of Medicine, Universidad de los Andes, Colombia. Standage is with the Dept University of Jyvaskyla, Finland. Maddison is with the National Institute for for Health, University of Bath, United Kingdom. Tomkinson is with the Health Health Innovation, University of Auckland, New Zealand. Ocansey is with the and Use of Time Research Group, Sansom Institute for Health Research, Active Lifestyle and Wellness Association Ghana, Healthy Active Kids-GH, University of South Australia, Adelaide, Australia. S113 S114 Tremblay et al using the best available evidence in their jurisdiction. The global Global Matrix Results matrix not only assesses global variation in indicators related to PA, but also serves as a tool to motivate change, facilitate advocacy, and Table 4 presents the global matrix in rank order by grade. For most cross-fertilize efforts aimed at empowering the movement to get kids indicators there is a large spread in grades across countries. Coun- moving around the world. tries that are leading in certain indicators are lagging in others. Over- all the grades for indicators of PA behavior around the world are low/ Global Matrix Participants and Procedures poor. Many countries have insufficient information to assign a grade, particularly for the Active Play and Family and Peers indicators. Plans to engage countries to participate in the Global Summit on the Grades for Sedentary Behavior in general are better in low-income Physical Activity of Children began in 2012. Through individual con- countries. The Community and Built Environment indicator received tacts, word of mouth, the International Study of Childhood Obesity, high grades in high-income countries and notably lower grades in Lifestyle, and the Environment principal investigators,23 and Internet lower-income countries. There was a pattern of higher PA and lower notices, researchers were encouraged and coached to develop a Report sedentary behavior in countries reporting poorer infrastructure and Card for their respective countries for release or presentation at the lower PA and higher sedentary behavior in countries reporting better Global Summit. Three countries (Kenya, Mexico, South Africa) com- infrastructure. Similarly, some countries have relatively high grades pleted their Report Cards for the second or third time. The general for the policy environment but relatively low grades for the health process for developing a Report Card included the aggregation and behavior indicators the policies are targeting. consolidation of the best available evidence and information synthesized into public facing, policy-focused, and research-based outputs, most Discussion notably the Report Card.1–5 Although the AHKC Report Card has had as many as 24 indicators graded in a given year, a decision was made Perhaps the most notable finding from the global matrix is the a priori to condense the indicators to 9 for the purpose of the global substantial variation in the grades assigned to the 9 indicators of matrix comparisons. The indicators included 5 behaviors: Overall PA. This is encouraging for at least 3 reasons. First, it demonstrates Physical Activity, Organized Sport Participation, Active Play, Active that at least some countries are succeeding in each of the important Transportation, Sedentary Behavior; and 4 key influences: Family and indicators examined in the global matrix. Second, such international Peers, School, Community and Built Environment, and Government variation consolidated in this fashion presents an opportunity for Strategies and Investments. The grading framework and benchmarks cross-fertilization of ideas for improving the grades. Third, the global that guided the process of assigning a grade to each indicator are pro- matrix provides a framework for research aimed at understanding the vided in Tables 1 and 2, respectively. Because the quality and quantity differences between and within different nations (eg, urban versus of data and evidence available in each country varied substantially, rural differences). It is also clear from Table 4 that no one country is the benchmarks also varied. To be as comprehensive as possible when leading or lagging in all indicators but, rather, each country has its assessing the evidence to inform the grades for factors influencing PA, own blend of successes and challenges at this point in time. Overall several benchmarks were considered (Table 2). This process has been there is much that needs to be done to enhance the PA behaviors and used for the AHKC Report Cards for the past 10 years. The Expert opportunities for children and youth around the world, and tackling Group in each country discussed the total evidence base before reach- this challenge together may provide unique insights that could not be ing consensus on the grade assigned for each indicator. To enhance the achieved in isolation. A discussion of who is leading and lagging in comparability of grades among jurisdictions, standardized guidance each indicator is presented below in the context of existing interna- was provided by the AHKC Report Card leaders, including participa- tional research. Subsequently, important disparities and inequities, tion in most grade assignment processes. Expert Groups consisting of research and surveillance gaps and needs, recommendations for childhood PA researchers, practitioners, and leaders from each country improving the grades, and future directions are discussed. were invited to identify available information and serve as a consensus committee for assigning grades. Country-specific details for each Report Who is Leading and Lagging? Card are summarized in the individual papers in this special issue of the journal.1,9–22 Despite variation in country data sources and the extent Overall Physical Activity. New Zealand and Mozambique reported to which country Expert Groups were able to apply the recommended the highest grades (“B”) for Overall Physical Activity while 10 benchmarks, it is believed that the grades across all indicators are countries reported low or failing grades (“D” or “F”), suggesting comparable and certainly informative of global variation in important there is widespread evidence of a childhood physical inactivity factors related to PA among children and youth. Internet links to the crisis. This was consistent with a comprehensive analysis that Report Cards for each country are provided in Table 3. included data from 105 countries around the world: only 20% of Table 1 Grading Framework for the Report Card Grade Interpretation A We are succeeding with a large majority of children and youth (≥ 80%) B We are succeeding with well over half of children and youth (60–79%) C We are succeeding with about half of children and youth (40–59%) D We are succeeding with less than half but some children and youth (20–39%) F We are succeeding with very few children and youth (< 20%) Downloaded by on 01/29/19 Global Matrix of Grades S115 Table 2 Benchmarks Used to Guide the Grade Assignment for Each Indicator Indicator Benchmark Overall Physical Activity % of children and youth who meet physical activity guidelines Organized Sport Participation % of children and youth who participate in organized sport and/or physical activity programs Active Play % of children and youth who engage in unstructured/unorganized active play for several hours a day Active Transportation % of children and youth who use active transportation to get to and from places (school, park, mall, friend’s place) Sedentary Behavior % of children and youth who meet sedentary behavior or screen-time guidelines Family and Peers % of parents who facilitate physical activity and sport opportunities for their children (eg, volunteering, coaching, driving, paying for membership fees and equipment) % of parents who meet the physical activity guidelines for adults % of parents who are physically active with their kids % of children and youth with friends and peers who encourage and support them to be physically active % of children and youth who encourage and support their friends and peers to be physically active School % of schools with active school policies (eg, Daily Physical Activity, recess, “everyone plays” approach, bike racks at school, traffic calming on school property, outdoor time) % of schools where the majority (≥ 80%) of students are taught by a PE specialist % of schools where the majority (≥ 80%) of students are offered at least 150 minutes of PE per week % of schools that offer physical activity opportunities (excluding PE) to the majority (≥ 80%) of their students % of parents with children and youth who have access to physical activity opportunities at school in addition to PE % of schools with students who have regular access to facilities and equipment that support physical activity (eg, gymnasium, outdoor playgrounds, sporting fields, equipment in good condition) Community and the Built Environment % of children or parents who perceive their community/municipality is doing a good job at promoting physical activity (eg, variety, location, cost, quality) % of communities/municipalities that report they have policies promoting physical activity % of communities/municipalities that report infrastructure (eg, sidewalks, trails, paths, bike lanes) spe- cifically geared toward promoting physical activity % of children or parents with facilities, programs, parks, and playgrounds available to them in their community % of children or parents living in a safe neighborhood where they can be physically active % of children or parents reporting well-maintained facilities, parks/playgrounds in their community that are safe % of children and youth who report being outdoors for several hours a day Government Strategies and Investments Evidence of leadership and commitment in providing physical activity opportunities for all children and youth Allocated funds and resources for the implementation of physical activity promotion strategies and ini- tiatives for all children and youth Demonstrated progress through the key stages of public policy making (ie, policy agenda, policy for- mation, policy implementation, policy evaluation, and decisions about the future) Abbreviations: PE, Physical Education. 13- and 15-year-olds reported getting at least 60 minutes of daily Significant variation in sampling and measurement procedures moderate- to vigorous-intensity physical activity (MVPA).24 While among countries limits comparison and understanding of PA behav- Report Card grades were generally higher in low-middle income iors. These limitations have been discussed in detail elsewhere.25–28 countries (Mozambique, Kenya, Mexico, Nigeria), this relationship Nevertheless, international comparisons can illustrate potentially was not uniform as New Zealand reported a high grade and Ghana important patterns and trends. For example the Mozambique a low grade for Overall Physical Activity. Report Card manuscript ascribes the inherently high activity level Downloaded by on 01/29/19 S116 Tremblay et al Table 3 Internet Addresses for Individual Country Report Cards Jurisdiction Weblink Australia www.activehealthykids.com.au Canada www.activehealthykids.ca Colombia epiandes.uniandes.edu.co England www.activehealthykidsengland.co.uk Finland www.jyu.fi/sport/ReportCard Ghana alwag.org/family/ahk-gh/rc2014 Ireland www.getirelandactive.ie/get-info/reportcard Kenya www.hakkenya.org Mexico obesired.mx/blog Mozambique www.up.ac.mz/cidaf/reportcard New Zealand www.nihi.auckland.ac.nz/PhysicalActivityReportCard Nigeria http://nigerianheart.org/articles.php?xid=1 Scotland www.activehealthykidsscotland.co.uk South Africa https://www.vitalityschools.co.za/schools/educationaltools/research.do United States www.physicalactivityplan.org of children to necessary active transportation and household and Organized Sport Participation. Most countries had sufficient subsistence chores,17 similar to Kenya;15 however, New Zealand’s evidence to grade the Organized Sport Participation indicator. grade seems to be achieved primarily through organized sport par- New Zealand and Australia reported the highest grades, with ticipation and active play.18 approximately two-thirds of children in these countries participating The more global observation that PA levels of children and in organized sport.9,18 Most countries clustered around a “C” grade, youth in many countries are low is supported by self-reported PA indicating that about one-half of children and youth participated in data for children and youth from 39 countries around the world: sport. Evidence from Australia41–43 and the United States44 suggested only 23%, 19%, and 15% of 11-, 13-, and 15-year-olds, respectively, that these relatively high grades were set to continue given recent reported at least 60 minutes of daily MVPA.29 Intuitively it seems increases (+5% points per decade) in the prevalence of children that PA levels of children and youth have declined in recent decades. who regularly participated in organized sport. The Mozambique Some circumstantial evidence supports this intuition including Report Card (“F”) suggested that the opportunity and availability an examination of anthropological and lifestyle transitions.30–34 of organized sport were limited, though data were lacking. Although empirical surveillance evidence to support the temporal Evaluation of grades for Organized Sport Participation, on one decline in childhood and adolescent PA levels appears lacking, such hand, and School and Community and the Built Environment, on the evidence may be constrained by measurement issues.28 other, suggested a relationship among these indicators. Countries Temporal changes in physical fitness are supportive of a decline with relatively good grades for Organized Sport Participation also in habitual PA. An analysis of survey data for over 25 million 9- reported relatively good grades for School and Community and to 17-year-olds from 28 countries has demonstrated international the Built Environment (eg, Australia, Canada, Finland), whereas declines in the ability of children and adolescents to perform aerobic countries with low grades for Organized Sport Participation reported exercise (–4% per decade) since 1975.35,36 Canadian data have also low grades for School and Community and the Built Environment shown a dramatic decrease in fitness levels in one generation.37,38 (eg, Colombia, Mexico, Mozambique). This makes sense since There is considerable geographical variability in aerobic fitness, organized sport and PA opportunities require space, facilities, with children and adolescents from Northern Europe performing equipment, and supervision. While most countries had some data the best (mean percentile ± 95% CI: 72 ± 0.4%), followed by Afri- on sport participation, details of the quality, frequency, duration, can children (55 ± 2.0%), those from the Pacific Rim (50 ± 1.6%), intensity, context (eg, physical education, extracurricular, com- Central/Western Europe (50 ± 0.4%), Southern Europe (36 ± 3.2%), munity sport), and seasonality of participation varied significantly and South America (30 ± 0.4%).39 Because of this geographical and/or were generally lacking. variability, the global declines are much more important in children Active Play. The 2012 AHKC Report Card asked the question and youth from countries that have poorer baseline aerobic fitness. “Is active play extinct”?5,45 It cited evidence showing low levels of A recent systematic review examining temporal trends in PA and active play (defined here as freely chosen, spontaneous and self- fitness among children and youth in sub-Saharan Africa found directed physical activity involving an element of fun46,47) in Canada insufficient evidence to determine any clear changes over time.40 and evidence of downward trends.5,45 Active play has historically The review did find adverse associations between PA, sedentary occurred outdoors but with the allure of electronic screens, children behaviors, and fitness, and urban living and higher socioeconomic and youth are increasingly spending their time indoors and usually status, suggesting that traditional economic development may sedentary (see Sedentary Behavior indicator below). Although paradoxically be related to reduced healthy active lifestyles and Canadians value outdoor time, they strongly agree that children do fitness.40 not spend enough time outdoors.48 Only 5 countries felt they had Downloaded by on 01/29/19 S117 Downloaded by on 01/29/19 Table 4 Global Matrix Presented in Rank Order by Grade Organized Government Overall Physical Sport Active Sedentary Family & Community & Strategies & Grade Activity Participation Active Play Transportation Behaviors Peers School Built Environment Investments A+ A A- England Australia B+ Canada B Mozambique New Zealand New Zealand Finland Ghana Finland England Colombia New Zealand Kenya Kenya Finland Finland Mozambique Ireland Scotland Nigeria Scotland South Africa B- Australia Mexico Australia United States New Zealand C+ Mexico Canada Canada Australia C Kenya Finland Kenya England New Zealand Australia Kenya New Zealand Canada Nigeria Ghana Mozambique Canada Mozambique Kenya Kenya Scotland Finland Mexico South Africa South Africa Kenya Mozambique New Zealand C- England Nigeria New Zealand Ireland Ireland Ireland United States United States D+ England D Colombia Colombia Finland Australia Colombia Ghana Ghana Ghana Ghana Mexico Canada Finland Mexico South Africa Finland Ghana Mexico South Africa South Africa Ireland United States D- Australia Australia Scotland Canada Ireland United States (continued) S118 Downloaded by on 01/29/19 Table 4 (continued) Organized Government Overall Physical Sport Active Sedentary Family & Community & Strategies & Grade Activity Participation Active Play Transportation Behaviors Peers School Built Environment Investments F Scotland Mozambique United States Canada Colombia Mexico Mozam- Nigeria bique Scotland South Africa INC Nigeria Australia Colombia England Colombia Nigeria Colombia England Scotland Canada Mozambique England Kenya Ireland Colombia Ghana Nigeria New Zealand England Ireland United States Ghana Mexico Nigeria Ireland Mozambique Mexico Nigeria Scotland South Africa South Africa United States United States Note. The grade for each indicator is based on the percentage of children and youth meeting a defined benchmark: A is 81%–100%; B is 61%–80%; C is 41%–60%, D is 21%–40%; F is 0%–20%. No grade was assigned when the data were considered to be incomplete (INC). The Overall Physical Activity indicator in the England Report Card was scored as C/D and for the purpose of the international comparison a D+ assigned. Global Matrix of Grades S119 enough data to grade this indicator. Grades ranged from “B” in New (–7 percentage points per decade, 1994–2005),70 the United King- Zealand to “D” in Finland. Data from New Zealand indicated that dom (–6 percentage points per decade, 1975–2012),71–73 and the approximately three-quarters of children reported participating in United States (–8 percentage points per decade, 1969–2009).74,75 active play,49 spending on average 78 minutes per day in free play.50 Parents in Canada76 and Kenya32 have reported that their children In contrast, the Finland Adolescent Health and Lifestyle Survey51 do not use active transportation as frequently as they (parents) found only one-third of 12- to 18-year-olds participated in physical did as children. Circumstantial evidence of a temporal decline in activities outside school or sports clubs at least 4 times per week.52 Ten active transportation other than to/from school can also be gleaned countries graded this indicator as “incomplete” because of insufficient from evidence of a restriction of independent mobility afforded to data and/or lack of clarity on the benchmark or the definition of active children,77 which would limit their active travel opportunities. For play. Canada has struggled with grading this indicator across its 10 example, temporal trends in socially or culturally acceptable roam- years of producing Report Cards for similar reasons.3 ing distances where children are allowed to wander freely almost It is commonly believed in developed countries that active, certainly vary substantially across and within countries although this unstructured (free) play is decreasing for a variety of reasons, is poorly understood. Furthermore, active transportation, whether for including increased screen time, safety concerns (eg, traffic, stranger school, work, chores, or play varies dramatically between urban and danger), emphasis on organized youth sports, and parental work rural settings, particularly in developing countries where automobile schedules. The same concern is emerging in developing countries, transport is often not available.30–32 It will be important to carefully especially in urban and peri-urban areas.31,32 If active play was monitor active transportation behaviors in rural areas in developing MVPA it should be captured in the Overall Physical Activity grade. countries as they transition to motorized transport and subsistence However, most active play is likely light-intensity PA, and the demands become increasingly mechanized. importance of light/incidental PA, especially in the form of active play, is largely unknown and likely varies significantly among Sedentary Behavior. As with other indicators there is significant countries and in urban and rural areas in lesser developed countries. global variation in sedentary behaviors although the majority Furthermore, incidental active play may be sporadic and difficult of countries have very poor or failing grades. Ghana and Kenya to quantify or recall through self-report, and impossible to discern reported the best grades on this indicator; well over half of children with pedometers or accelerometers. Interestingly, children aged and youth reported spending no more than 2 hours per day on screen 7–12 years from 25 countries were interviewed about their favorite time. Intuitively it seems that less access to sedentary behavior pastime and “playing with friends” was the top response (30%); it promoting devices (eg, motorized vehicles, electronic screens) was more popular among children in Scandinavian countries and would be associated with less sedentary behavior. Indeed, recent Japan (≥ 40%).53 Data from the United States between 1981–2003 research comparing 17 high-, middle-, and low-income countries showed that for children aged 6–12 years “playing” was the most demonstrated that ownership of household devices, including common pastime after television viewing.34 televisions, computers, and cars, increased as country income level increased, and that ownership was positively associated with obesity Active Transportation. All countries except Colombia graded and diabetes in low- and middle-income countries.64 Of particular the Active Transportation indicator, with grades ranging from “B” relevance to the present discussion, this relationship was partially in Finland, Kenya, Nigeria, and Mozambique to “F” in the United mediated by decreased PA and increased sedentary behavior.78 States. Active transportation may be a necessity for some children in As the world becomes increasingly “wired,” auto-dependent and countries such as Nigeria,19 Kenya,15 and Mozambique,17 whereas it urbanized, the temptation and convenience of sedentary living may be more a cultural norm in Finland. In Finland, approximately seems likely to increase. Self-report sedentary behavior data on 75% of children and youth actively commuted to school when the representative samples of children and youth from 39 countries distance ≤ 3 km.54 In contrast, in the United States < 15% of children around the world revealed that 56%, 65%, and 63% of 11-, 13-, and and youth used active transportation to get to and from school.22 15-year-olds, respectively, watched 2 or more hours of television The most robust data available in most countries related specifically per day on weekdays.29 In a study of parents from 25 countries to active school transportation.55,56 The percentage of children and around the world, 44% of parents agreed that their children spent youth in Canada, the United States, the United Kingdom, Australia, too much time watching television or playing electronic games.53 and New Zealand who cycled to/from school was generally low, The overall findings from the global matrix and international whereas the prevalence of cycling or walking to/from school in surveys suggest that when sedentary behaviors are high, PA levels countries from continental Europe and in China was relatively high are low. As a result, there is growing recognition of the importance compared with what is seen in North America, the United Kingdom, of reducing sedentary behavior in children in addition to promoting and Australasia.57 PA.79,80 Canada has recently developed specific Sedentary Behav- Studies from North America typically report lower levels of iour Guidelines81,82 that are separate and distinct from existing PA active school transport in secondary school students than in primary guidelines. The United Kingdom83 and Australia84–86 have also school students.58–62 This age-related or school transition-related recently made specific recommendations about limiting sedentary decline may not be universal and may not always follow the age- time to promote healthy growth and development of children. Such related decline generally seen in overall PA. For example, Ireland guidelines or recommendations are not common yet in developing did not observe such declines in active transportation.14 countries and it seems public health messaging around limiting Even though active transportation has been associated with screen time in particular may be important as lifestyle transitions increased PA and fitness63 evidence suggests that levels of active occur throughout the world. It is important to note that screen time transportation are declining.64,65 There have been consistent declines consists of much more than traditional television viewing which in children’s use of active transportation in recent decades, with should be reflected in future surveillance. While the sedentary declines in the prevalence of cycling or walking to/from school behavior indicator was informed in all countries exclusively by observed in Australia (–7 percentage points per decade, 1971– screen-time, or specifically television viewing time, nonscreen 2004),42,66,67 Brazil (–16 percentage points per decade, 2002–07),68 sedentary behaviors, and their relationship with health outcomes Canada (–8 percentage points per decade, 1986–96),69 Switzerland are important to understand and require further research. Downloaded by on 01/29/19 S120 Tremblay et al Family and Peers. While the importance of family and peer the actual reported use of parks, playgrounds, and programs was support for the promotion of PA is universally recognized and quite low.95 It appears that perceptions of quality and safety of substantiated by recent reviews,87–90 this indicator is very difficult local facilities and infrastructure did not necessarily translate into to grade based on a lack of empirical data adhering to the grading PA. On a more global scale, this same relationship appeared to framework (Table 1). This difficulty was apparent in the report emerge with countries that reported rather good PA environments card grades summarized in this overview: 9 countries assigned in the community generally showing poor Overall Physical Activity an “incomplete” grade due to lack of data. The countries that did grades, while countries with lower grades on Community and Built assign grades were tightly clustered around a “C” grade, with less Environment generally showing higher Overall Physical Activity variability than for any other indicator. As can be seen from Table grades. 2, a variety of benchmarks were used to inform this indicator, with Other results from several countries have also challenged the availability of data to grade against each benchmark varying conventional thinking about the relationship between PA and char- among countries.1,9,12,15,18,20 A survey of parents in 25 countries with acteristics of the built environment.96 Using latent class analysis of children birth to 12 years of age in 2010 noted an average of 14.3 built environment features reported by adults from 11 countries, 5 hours per week spent with their children in all types of play during neighborhood patterns emerged across countries; 2 were specifi- a typical week; means ranged from 10.5 hours in Denmark to 20.0 cally associated with meeting PA guidelines: first, an overall activity hours in China.53 Note, however, that family size and composition, supportive environment (eg, many shops and transit stops within employment logistics, urban-rural residence, climate, and variable walking distance, sidewalks on most streets, low cost recreation definitions of “play” may confound the results and interpretations. facilities near-by), and second, highly walkable yet unsafe envi- Hence, given the available data, it is difficult to draw any firm ronments with few recreation amenities.96 Although this study was conclusions from these findings. adult-centric, the results add evidence that relationships between the environment and PA are complex and probably specific to geo- School. Grades for the School indicator ranged from “A-” in graphic area, culture, and/or country.96 England to “F” in Colombia with a relatively even distribution of While there is universal support for the promotion of PA grades by other countries between these extremes. The top 5 grades enhancing environments, evidence suggests a need to challenge how were from high-income countries while the bottom 4 grades were such environments should be defined. In some cases, it may be that from middle- to low-income countries. The high grade for England “less is more” for the promotion of exploratory play and incidental represented favorable composite evidence on school physical PA for some children. Nevertheless, international comparisons as education (PE) delivery, school policies and investments in PA, and evident in the global matrix and other surveys96 are invaluable in school facilities and availability.11 The low grade in Colombia was assessing the universality of interventions and approaches, while based on the observation that only 6.1% of school-aged children received PE classes from a professional instructor.91 emphasizing the need to use cross-cultural research in the search Of interest, for solutions to the childhood inactivity crisis. grades for the Overall Physical Activity indicator did not appear to be closely related to school-based opportunities for PE or PA. Government Strategies and Investments. The Government International comparisons of PE and school-based delivery of Strategies and Investments indicator was difficult to grade. Assigned PA are scarce. A recent comparison of 30 European countries around grades relied more on expert consensus than the grading framework initiatives and strategies to promote PE and PA in schools, time (Table 1). Nevertheless, 10 countries felt confident assigning a spent on PE, curriculum details, PE assessment, teacher education, grade. Grades were tightly bunched in the “B” and “C” range and extracurricular sports highlighted important differences across indicating an overall favorable assessment, regardless of the income Europe,92 and noted that PE in some European countries was now < or development status of the country. The individual country report 10% of total curricular time.92 Elsewhere, it has been reported that cards discussed a variety of policies, strategies, and investments the quality and/or quantity of PE has recently diminished in many related to different indicators and collectively represent a catalog countries in recent years, with losses of 15%–20% of weekly time of ideas for governments to consider.1,9–22 allocation due to cost-reduction or time allocation for other school Many countries had relatively high grades for the policy subjects,69,93,94 though areas of Australia have actually shown small environment both in schools and in governments, but relatively increases.42,66 Moreover, there is a discrepancy between curricular low grades for the indicators of health behaviors that the policies schedules and actual practice in many countries,93 an issue raised in were targeting. Whether this reflects ineffective policies, lack of the Kenya and Ireland report cards.14,15 Unsatisfactory infrastructure, implementation or the reactive nature of policy development is lack of equipment and financial resources, lack of training of PE unclear. The fact that more developed countries had more developed teachers, a gap between policy and practice, curricular demands policy environments than less developed countries, but generally that exceed teacher competence, and over-sized classes are other had lower levels of desired behaviors indicates a major mismatch concerns raised by PE leaders from around the world.93 (ie, policies and strategies may have been reactive to problems after they had emerged rather than preventive). Further, the implemen- Community and the Built Environment. This indicator received tation of reparative policies may be suboptimal (eg, ineffective, the highest grades, on average, with 7 countries assigning grades ≥ unsustainable, insufficiently scaled). Given the experience from of “B-.” While the grades were generally high, they ranged from developed countries, it may be opportune to rally support for the “A-” in Australia to “F” in Mexico and Mozambique. A general implementation of proactive campaigns, strategies, and investments pattern of higher grades in higher-income countries and lower in developing countries in an effort to preserve inherent healthy grades in lower-income countries was evident, which makes intuitive active living behaviors. sense. Although there is much emphasis on improving the built environment, it is already reported as quite good in many countries. Other Indicators. While not discussed in the context of the global Canadians quite reliably reported rather good PA infrastructure, matrix it is worth noting that most countries added additional availability, and programming.3 Despite consistent high grades indicators to their Report Cards; indicators of particular relevance for the Community and Built Environment indicator in Canada, or importance to their jurisdiction. Examples of additional indicators Downloaded by on 01/29/19 Global Matrix of Grades S121 included body weight status (overweight and/or obesity, in some disparity or inequity gradient related to the Organized Sport Par- cases in the presence of persistence underweight), nutrition/ ticipation indicator. Because participation in organized sport often healthy eating indicators, physical fitness, motor skills, and requires resources (registration fees, equipment, travel), it is more nongovernmental strategies and investments. Details are reported susceptible to socioeconomic or geographic (urban-rural) gradients. in individual country Report Cards.1,9–22 Such gradients were noted in several Report Cards. Most countries also reported a gender bias favoring boys in organized sport par- Disparities and Inequities ticipation. International and cultural variation in gender roles and expectations complicate the transferability of interventions to help Variability in the grades comprising the global matrix demonstrates level the playing field between genders. disparities and inequities in indicators related to PA at the country level. Such variation, while generally considered in need of repair to “level the playing field,” provides rich, comparative information Research and Surveillance Gaps and Needs that can assist jurisdictions and challenge conventional wisdom. For • While this global matrix with 15 nations is a major advance, example, should higher-income countries be encouraged to relax there are a number of “geographical gaps,” notably the lack efforts to construct environments for children to play (thereby lower- of representation from Asia, the Eastern Mediterranean, and ing their grades), or should low-income countries be encouraged to Arab countries, much of Eastern and Western Europe, South invest in constructing environments shown to promote PA in other America, Pacific Islands, and the Caribbean (see Figure 1). It is jurisdictions (thereby improving their grades)? hoped that the creation of the first global matrix will encourage It is worth highlighting that very little information on the acces- nations from these under-represented areas to develop Report sibility and opportunity for PA among children and youth with a Cards in the future and further our understanding of global disability (physical, mental, sensory) was reported in the country variation while assisting with solution cross-fertilization. Report Cards. This group with special needs not only represents a Efforts are currently underway in at least 4 additional countries significant proportion of children and youth globally,97,98 it is among (Hong Kong, Japan, Malaysia, Wales). the most vulnerable to physical inactivity and also the group that might gain the greatest benefit from a “level playing field.” The • There is a need for more research on the correlates and deter- prevalence of children and youth with disabilities varies substan- minants of PA and sedentary behaviors in children and youth tially among countries and disability category.98 Understanding in different countries. Determinants likely vary by region and and learning from international variability in efforts to address across cultures. This information is essential to the identifica- disparities and inequities among this marginalized population could tion of future Report Card indicators and novel intervention increase awareness and provoke required changes. This is an area possibilities. where more research and surveillance is required. • There is a need for robust, standardized measures of PA and Disparities and inequities exist within countries, but the extent sedentary behaviors on children and youth from countries varies among countries.1,9–22 The most notable within-country around the world. Figure 1 — Global map indicating location of countries participating in the global matrix. Downloaded by on 01/29/19 S122 Tremblay et al • There is a need for healthy movement behavior information • International, cross-cultural efforts should be used to inform on young children (toddlers and preschoolers, aged 1–5 years) creative solutions and interventions to influence the habitual from countries around the world to understand best practices movement behaviors of children around the world, recognizing for the promotion of healthy growth and developmental trajec- the variation in social norms and environmental realities while tories. respecting the biologically rooted and curiosity-driven desires • More research and surveillance are required to assess the and impulses of children and youth. Countries should take levels and importance of active, unstructured play and/or light- advantage of policy work/documents that have been developed intensity PA and understand their relationship with holistic in other countries (eg, PA strategies, active play plans, cycle health outcomes. frameworks). An inventory and library of existing documents in each country should be created for reference purposes. • Enhanced efforts are required to collect public health surveil- lance data for those indicators that could not be graded (graded • Volunteerism can be an important nongovernmental, commu- incomplete); to improve the measurement of existing indica- nity-based support for sport and PA. While delivery of sport and tors with better, standardized measures and more representa- PA opportunities should not be reliant on volunteers, models tive samples; to extend measures to include emerging health of practice worldwide on how to involve and retain volunteers behaviors which have not been measured in surveillance in the or lay leaders would be useful. past (eg, sitting time, breaks in sitting time, nonscreen time sedentary behaviors, light PA); and to include marginalized Conclusion groups. The global matrix provides new information upon which research- Though not specific to the global matrix a recent Delphi ers, advocates, practitioners, and policy-makers can reflect and survey of international experts established a ranked set of interna- derive inspiration for future work. International cooperation and tional research priorities in child and adolescent PA and sedentary cross-fertilization is encouraged to conquer existing challenges, behavior.99 The top 3 priorities were: development of effective and understand underlying mechanisms, derive innovative solutions sustainable interventions to increase long-term PA among children and overcome the expanding childhood physical inactivity crisis. and youth; assessment of policy and/or environmental changes and their influence on PA and sedentary behaviors of children and Acknowledgments youth; and implementation of prospective, longitudinal studies to examine the independent effects of PA and sedentary behaviors on The authors would like to thank Active Healthy Kids Canada, especially health from birth to middle age.99 Jennifer Cowie Bonne and Lindsay Whiting, for their leadership in planning and hosting the Global Summit on the Physical Activity of Children. The Recommendations for Improving the Grades and authors are indebted to the individual country Report Card Project Manag- Future Directions ers and/or Scientific Officers including: Dr. Natasha Schranz (Australia), Joel Barnes (Canada), Dr. Silvia Gonzalez (Colombia), Hannah Wilkie • Expand our work as a global community of childhood PA (England), Dr. Catherine Woods (Ireland), Stella Muthuri and Joy Wachira researchers and advocates to learn from one another and chal- (Kenya), Karla Galaviz (Mexico), Adewale Oyeyemi (Nigeria), Dr. Smita lenge conventional within country solutions with international Dick and Prof. Geraldine McNeill (Scotland), Monika Uys (South Africa), cross-fertilization of ideas and approaches. This may be facili- and Kara Dentro (United States). tated by the creation of a global federation or network of active healthy kids organizations or research or advocacy groups. 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