Population-based physical activity promotion with a focus on health equity: a review of reviews.

BACKGROUND: The extent to which people are physically active is dependent upon social gradients. Numerous studies have shown that especially people with social disadvantages do not meet the physical activity (PA) recommendations. A promising strategy to alleviate this issue are approaches that promote PA in the general population. In addition, several researchers have raised concerns that population-based health interventions may increase health inequities. The aim of the current review of reviews was therefore to identify successful population-based PA promotion approaches with a particular focus on health equity. METHODS: Six electronic databases were examined for systematic reviews on population-based PA promotion for the period 2015 to 2021. A reference list and grey literature search were also conducted. Two independent reviewers used inclusion/exclusion criteria to screen titles and abstracts of the potentially relevant literature and conducted a quality assessment for each identified review. All included reviews of population-based approaches for PA promotion with a focus on disadvantaged populations and/or health equity were narratively summarized. RESULTS: Our search resulted in 4,411 hits. After a systematic review process, six reviews met the inclusion criteria and were included after they were all rated as high quality. We identified that mass-media campaigns, point-of-decision prompts, environmental approaches, policy approaches, and community-based multi-component approaches can promote PA in the general population. Across populations with social disadvantages mass-media campaigns, point-of-decision prompts and policy approaches are likely to be effective as long as they are tailored. Regarding environmental approaches, the results are inconsistent. None of the reviews on community-based multi-component approaches provided evidence on health equity. CONCLUSION: There are several effective approaches to promote PA in the general population but evidence regarding health equity is still sparse. Future studies should therefore pay more attention to this missing focus. Furthermore, there is a lack of evidence regarding the type of tailoring and the long-term impact of population-based approaches to PA promotion. However, this requires appropriate funding programmes, complex study designs and evaluation methods.

Multi-level stakeholders' perspectives on implementation and scaling up community-based health promotion in Germany.

Community-based health promotion has the potential to address existing health inequities, although such approaches are scarcely scaled up. For a successful scale up, various stakeholders at different levels and sectors need to be involved. The article's aims are to assess what kind of external support communities need for implementation and to identify facilitators and barriers for scaling up community-based health promotion. Two national digital workshops were conducted in Germany with stakeholders at the community level (n = 161) and with stakeholders at the federal and state levels (n = 84). Protocols were compiled and coded using qualitative content analysis. During the first workshop, we revealed 11 themes for external support needs ('Strategic approach', 'Define & compare indicators', 'International human resource', 'Tools & Aids', 'External conduction of the assessment', 'Involvement of people in difficult life situations', 'Overview of actors', 'Moderation', 'Obtain funding', 'Quality assurance/evaluation' and 'External support'). Eleven facilitators and barriers were identified for scaling up ('Assessment and evaluation', 'Intersectoral collaboration and partnerships', 'Communication', 'Characteristics of the program', 'Political and legal conditions', 'Political support', 'Local coordinator', 'Resources', 'Participation', 'Strategic planning/methods' and 'Intermediary organization'). The identified results provide practice-based evidence on support needed for scaling up, facilitators that promote scaling up and barriers that might hinder scaling up community-based health promotion in Germany. In a next step, this practice-based evidence needs to be systematically integrated with scientific-based evidence on key components for scaling up such approaches for the development of an effective scaling-up concept.

The major aim of this article is to describe how German stakeholders at different levels (local, federal and state) from various sectors (e.g. health, social or sports) were involved to develop a scaling-up concept for a community-based health promotion approach with a focus on health equity in the field of physical activity promotion. Different actors from science, policy and practice discussed facilitators and barriers for the scale up and what external support communities need to implement a community-based health promotion approach, with a focus on people in difficult life situations (e.g. individuals with social disadvantages). We identified 14 different kind of support needs and 11 facilitators and barriers for scaling up community-based health promotion approaches in the field of physical activity promotion. Various actors emphasized the need for improved collaboration and partnerships across several sectors as well as changes in current political and legal conditions. Furthermore, the role and some characteristics of an external organization to support a successful scaling-up process were also discussed among actors.

The capability approach as a bridging framework across health promotion settings: theoretical and empirical considerations.

Health promotion research has increasingly called for transdisciplinary approaches. Such calls ask for bridging frameworks that define comprehensive sets of health determinants and appropriately conceptualize the roles of population groups as well as other relevant actor groups in the co-production of health. This article aims to present the seminal capability approach by Sen and Nussbaum as a potentially suitable framework for such bridging endeavors to guide health promotion research. It highlights domains of the capability approach that appear to be particularly relevant to bridging diverse disciplines and settings. Such domains particularly refer to the agency of decisive actor groups (population groups, professionals, policymakers and researchers) as well as to the differentiation of personal, social and environmental conversion factors that disciplines define within their specific epistemologies and ontologies. The article uses empirical examples from a German research consortium that aimed to promote physical activity in five different settings while fostering cooperation and conceptual alignment between several academic disciplines and sub-disciplines to highlight benefits and challenges of using the capability approach as a bridging framework for transdisciplinary health promotion. We conclude that the capability approach might serve as bridging framework to guide future transdisciplinary research if partners involved continuously exchange to develop a shared understanding of the issues to be researched.

Co-producing an action-oriented framework for community-based Physical Activity Promotion in Germany.

German National Recommendations for Physical Activity (PA) and PA Promotion recommend community-based approaches to promote PA at the local level with a focus on health equity. In addition, the German Federal Prevention Act addresses health equity and strengthens setting-based health promotion in communities. However, the implementation of both in the local context remains a challenge. This article describes Phase 1 of the KOMBINE project that aims to co-produce an action-oriented framework for community-based PA promotion focusing on structural change and health equity. (i) In a series of workshops, key stakeholders and researchers discussed facilitators, barriers and needs of community-based PA promotion focusing on health equity. (ii) The research team used an inductive approach to cluster all findings and to identify key components and then (iii) compared the key components with updated literature. (iv) Key components were discussed and incorporated into a gradually co-produced framework by the participants. The first result of the co-production process was a catalog of nine key components regarding PA-related health promotion in German communities. The comparison of key components with scientific evidence showed a high overlap. Finally, a six-phase action-oriented framework including key components for community-based PA promotion was co-produced. The six-phase action-oriented framework integrates practice-based and scientific evidence on PA-related health promotion and health equity. It represents a shared vision for the implementation of National Recommendations for PA and PA Promotion in Germany. The extent to which structural changes and health equity can be achieved is currently being investigated in pilot-studies.

This paper describes how the participants in the KOMBINE project were involved in an innovative approach to transfer the German National Recommendations for Physical Activity (PA) and PA Promotion into the local practice of communities. Scientists, politicians and community actors (e.g. mayors, heads of sports departments) discussed their knowledge and experiences of facilitators, barriers and needs to promote PA in communities, specifically for people in difficult life situations (e.g. individuals with social disadvantages). Based on the results, they jointly developed key components and an action-oriented framework to implement the National Recommendations for PA and PA Promotion in German communities.

Capabilities for Physical Activity by Turkish- and Russian-Speaking Immigrants Aged 65 Years and Older in Germany: A Qualitative Study.

This study builds upon Sen's seminal capability approach to analyze the interplay of individual and structural factors for immigrants' physical activity (PA) in old age. The authors conducted software-assisted thematic analysis of group interviews with Turkish- and Russian-speaking immigrants aged 65 years and older in Germany (n = 19). The authors present how interviewees perceive diverse resources, environmental, social, and individual factors that shape their capabilities for PA. Age-related health literacy, family support, and access rules to sport opportunities shape both groups' capabilities for PA. Turkish interviewees' continuous bilocation and Russian interviewees' past experience with PA as workplace exercise are two major differences between those groups. Results indicate that capabilities are ambiguous-managed and shaped by individuals, which makes more static terms like barriers and options less helpful for an analysis. Systematically applying the capability approach in intervention research would allow to analyze interaction and to ultimately better reach underserved groups like immigrants 65 years and older.

Co-producing active lifestyles as whole-system-approach: theory, intervention and knowledge-to-action implications.

Population health interventions tend to lack links to the emerging discourse on interactive knowledge production and exchange. This situation may limit both a better understanding of mechanisms that impact health lifestyles and the development of strategies for population level change. This paper introduces an integrated approach based on structure-agency theory in the context of 'social practice'. It investigates the mechanisms of co-production of active lifestyles by population groups, professionals, policymakers and researchers. It combines a whole system approach with an interactive knowledge-to-action strategy for developing and implementing active lifestyle interventions. A system model is outlined to describe and explain how social practices of selected groups co-produce active lifestyles. Four intervention models for promoting the co-production of active lifestyles through an interactive-knowledge-to-action approach are discussed. Examples from case studies of the German research network Capital4Health are used to illustrate, how intervention models might be operationalized in a real-world intervention. Five subprojects develop, implement and evaluate interventions across the life-course. Although subprojects differ with regard to settings and population groups involved, they all focus on the four key components of the system model. The paper contributes new strategies to address the intervention research challenge of sustainable change of inactive lifestyles. The interactive approach presented allows consideration of the specificities of settings and scientific contexts for manifold purposes. Further research remains needed on what a co-produced knowledge-to-action agenda would look like and what impact it might have for whole system change.

How can the impact of national recommendations for physical activity be increased? Experiences from Germany.

BACKGROUND: Clearly stated national recommendations for physical activity (PA) are available in many nations. Yet, their impact on national level policy-making might be considered modest at best. This paper analyses the approach selected to curtail this problem in Germany. MAIN TEXT: Academics, government institutions and relevant stakeholders worked in collaboration to produce a series of national recommendations for PA and PA promotion published in 2016. Since their publication, these recommendations have achieved a measurable political impact through a systematic approach focused on dissemination and implementation strategies. For example, the German Conference of Health Ministers has acknowledged the national recommendations, endorsed their dissemination and proposed that they are included in measures within the Federal Prevention Act. CONCLUSION: Since their publication, the national recommendations have yielded satisfactory political impact. The contributing aspects might partially be explained by the Multiple Streams Approach.

Conceptualizing structural change in health promotion: why we still need to know more about theory.

As recently discussed in the public health literature, many questions concerning 'structural' approaches in health promotion seem to remain unanswered. We argue that, before attempting to provide answers, it is essential to clarify the underlying theoretical assumptions in order to arrive at the right questions one should ask. To this end, we introduce into the current debate an existing theoretical framework that helps conceptualize structural and individual aspects of health promotion interventions at different levels of action. Using an example from the field of physical activity promotion, we illustrate how an integrated framework can help researchers and health promoters rethink important issues and design better interventions. In particular, such an approach may help overcome perceived distinctions between different types of approaches, re-conceptualize ideas about the effectiveness of interventions, and appropriately address issues of health disparities.

[Quality Criteria for the Conception, Implementation and Evaluation of Interventions for Physical Activity Promotion: A State-Of-The-Art Review]. / Qualitätskriterien für die Konzipierung, Implementierung und Evaluation von Interventionen zur Bewegungsförderung: Ergebnisse eines State-of-the-Art Reviews.

The success of an intervention for physical activity promotion depends not only on the use of an evidence-based approach, but also on the quality of its implementation in practice. Based on current recommendations from scientists and public health institutions, this state-of-the-art review summarizes the quality criteria for the conception, implementation and evaluation of interventions.A systematic literature search was conducted in the electronic databases PubMed and Scopus. Additionally, guidelines from relevant public health institutions were identified via search engines and websites from governmental and nongovernmental organizations. Based on the analysis of selected documents, quality criteria were listed, grouped and categorized.24 documents, published between 2005 and 2015, provided quality criteria for interventions for physical activity promotion. From the selected documents, 18 quality criteria were defined (conception: 7, implementation: 7, evaluation: 4).This review provides evidence on the relevance of quality criteria within certain stages of an intervention. Future studies could compare the effect of quality criteria on the success of an intervention, or approach the topic from a health-economic perspective.

[Recommendations for Physical Activity Promotion: Theory and Evidence]. / Empfehlungen für Bewegungsförderung: Theorie und Evidenzbasierung.

This article defines a framework for the development of recommendations for physical activity promotion. It aims to provide a theoretical foundation and rationale for classifications of physical activity promotion and approaches for the evidence base of recommendations. Perspectives from contrasting scientific disciplines were compared regarding their theoretical approach for physical activity promotion and their influence on possible classifications. In addition, various approaches of an evidence base were analyzed and integrated into a differentiated concept for the evidence base of recommendations. From a public health perspective, the use of integrative multi-level-models is fundamental as they can be combined both with different classifications, and individual, social, environmental and policy-based approaches. The evidence base should include the efficacy, effectiveness and cost-effectiveness of an intervention.The scientific and political rationale for recommendations for physical activity promotion can be supported by an explicit theoretical framework and a differentiated concept of an evidence base.

[Are Interventions Promoting Physical Activity Cost-Effective? A Systematic Review of Reviews]. / Sind Präventionsmaßnahmen zur Bewegungsförderung kosteneffektiv? Ein systematischer Review von Überblicksarbeiten.

On the basis of international published reviews, this systematic review aims to determine the health economic benefits of interventions promoting physical activity.This review of reviews is based on a systematic literature research in 10 databases (e. g. PubMed, Scopus, SPORTDiscus) supplemented by hand searches from January 2000 to October 2015. Publications were considered in the English or German language only. Results of identified reviews were derived.In total, 18 reviews were identified that could be attributed to interventions promoting physical activity (2 reviews focusing on population-based physical activity interventions, 10 reviews on individual-based and 6 reviews on both population-based and individual-based physical activity interventions). Results showed that population-based physical activity interventions are of great health economic potential if reaching a wider population at comparably low costs. Outstanding are political and environmental strategies, as well as interventions supporting behavioural change through information. The most comprehensive documentation for interventions promoting physical activity could be found for individual-based strategies (i. e. exercise advice or exercise programs). However, such programs are comparatively less cost-effective due to limited reach and higher utilization of resources.The present study provides an extensive review and analysis of the current international state of research regarding the health economic evaluation of interventions promoting physical activity. Results show favourable cost-effectiveness for interventions promoting physical activity, though significant differences in the effectiveness between various interventions were noticed. The greatest potential for cost-effectiveness can be seen in population-based interventions. At the same time, there is a need to acknowledge the limitations of the economic evidence in this field which are attributable to methodological challenges and research deficits.

[A Systematic Review of Reviews of Interventions for the Promotion of Physical Activity: Methodology and First Results]. / Systematischer Review von Übersichtsarbeiten zu Interventionen der Bewegungsförderung: Methodologie und erste Ergebnisse.

As part of the development of recommendations for physical activity promotion, a review of reviews was performed. This article presents both the utilised methodology and first results.A systematic review of reviews was performed in PubMed, Scopus, Sport Discus, PsycInfo and other electronic databases. Reviews in English and German were included.213 reviews were identified for further analysis. A large number of reviews were identified for physical activity promotion among children and adolescents (74) and adults (66). In contrast, only 14 reviews dealt with physical activity promotion among older people.This review of reviews allowed for an analysis of the effectiveness regarding different intervention types for physical activity promotion. Depending on the target group and type of intervention, differences in quality of available evidence could be identified.

Building policy capacities: an interactive approach for linking knowledge to action in health promotion.

This article outlines a theoretical framework for an interactive, research-driven approach to building policy capacities in health promotion. First, it illustrates how two important issues in the recent public health debate, capacity building and linking scientific knowledge to policy action, are connected to each other theoretically. It then introduces an international study on an interactive approach to capacity building in health promotion policy. The approach combines the ADEPT model of policy capacities with a co-operative planning process to foster the exchange of knowledge between policy-makers and researchers, thus improving intra- and inter-organizational capacities. A regional-level physical activity promotion project involving governmental and public-law institutions, NGOs and university researchers serves as a case study to illustrate the potential of the approach for capacity building. Analysis and comparison with a similar local-level project indicate that the approach provides an effective means of linking scientific knowledge to policy action and to planning concrete measures for capacity building in health promotion, but that it requires sufficiently long timelines and adequate resources to achieve adequate implementation and sustainability.

Enabling the powerful? Participatory action research with local policymakers and professionals for physical activity promotion with women in difficult life situations.

Enabling is a concept central to health promotion. It is perceived as a mechanism that can help people gain control over determinants of health. Little is known, however, about enabling among policy-makers and professionals. This case study investigates enabling among policy-makers and professionals who engaged in a specific participatory approach, cooperative planning. We define 'enabling' as creating action situations that allow policy-makers and professionals to (i) build individual capacities for health promotion and to (ii) apply these capacities to concrete organizational and political action at the institutional level. This case study followed policy-makers and professionals as they participated in a local physical activity promotion action research project in Germany. We conducted a secondary analysis of qualitative data gathered in that project (2005-2011). Methods included participant observation, document analysis, focus groups and qualitative interviews. All data were revisited for the case study and analyzed using qualitative content analysis. Findings include examples of enabling among policy-makers and professionals related to the cooperative planning process. Individual capacities were developed in perceived project roles, interactions with target groups and decision-making procedures. Findings also demonstrated municipal policy changes. Access to physical activity infrastructures improved, and an intersectoral job position was funded to support physical activity promotion among target group participants. Findings were analyzed using a model that links cooperative planning with a framework on policy change from a political science perspective. We conclude that cooperative planning might be a pathway to negotiated agreements that foster systematic enabling and health-promoting policy change.

The Limitations and Potentials of Evaluating Economic Aspects of Community-Based Health Promotion: A Critical Review.

Community-based health promotion (CBHP) interventions are promising approaches to address public health problems; however, their economic evaluation presents unique challenges. This review aims to explore the opportunities and limitations of evaluating economic aspects of CBHP, focusing on the assessment of intervention costs and outcomes, and the consideration of political-level changes and health equity. A systematic search of the PubMed, Web of Science and PsycInfo databases identified 24 CBHP interventions, the majority of which targeted disadvantaged communities. Only five interventions included a detailed cost/resource assessment. Outcomes at the operational level were mainly quantitative, related to sociodemographics and environment or health status, while outcomes at the political level were often qualitative, related to public policy, capacity building or networks/collaboration. The study highlights the limitations of traditional health economic evaluation methods in capturing the complexity of CBHP interventions. It proposes the use of cost-consequence analysis (CCA) as a more comprehensive approach, offering a flexible and multifaceted assessment of costs and outcomes. However, challenges remain in the measurement and valuation of outcomes, equity considerations, intersectoral costs and attribution of effects. While CCA is a promising starting point, further research and methodological advancements are needed to refine its application and improve decision making in CBHP.

Physical inactivity as a policy problem: applying a concept from policy analysis to a public health issue.

Despite the recent rapid development of policies to counteract physical inactivity (PI), only a small number of systematic analyses on the evolution of these policies exists. In this article we analyze how PI, as a public health issue, "translates" into a policy-making issue. First, we discuss why PI has become an increasingly important public health issue during the last two decades. We then follow Guy Peters and conceptualize PI as a "policy problem" that has the potential to be linked to policy instruments and policy impact. Analysis indicates that PI is a policy problem that i) is chronic in nature; ii) involves a high degree of political complexity; iii) can be disaggregated into smaller scales; iv) is addressed through interventions that can be difficult to "sell" to the public when their benefits are not highly divisible; v) cannot be solved by government spending alone; vi) must be addressed through a broad scope of activities; and vii) involves interdependencies among both multiple sectors and levels of government.We conclude that the new perspective on PI proposed in this article might be useful and important for i) describing and mapping policies to counteract PI in different contexts; ii) evaluating whether or not existing policy instruments are appropriate to the policy problem of PI, and iii) explaining the factors and processes that underlie policy development and implementation. More research is warranted in all these areas. In particular, we propose to focus on comparative analyses of how the problem of PI is defined and tackled in different contexts, and on the identification of truly effective policy instruments that are designed to "solve" the PI policy problem.

Policy assessment and policy development for physical activity promotion: results of an exploratory intervention study in 15 European nations.

BACKGROUND: Purpose of the study was to test a theoretical model to assess and develop policies for the promotion of physical activity among older people as part of an international intervention study. METHODS: 248 semi-standardized interviews with policy-makers were conducted in 15 European nations. The questionnaire assessed policy-makers' perceptions of organizational goals, resources, obligations, as well as organizational, political and public opportunities in the area of physical activity promotion among older people. In order to develop policies, workshops with policy-makers were conducted. Workshop outputs and outcomes were assessed for four nations nine months after the workshops. RESULTS: Policy assessment: Results of the policy assessment were diverse across nations and policy sectors. For example, organizational goals regarding actions for physical activity promotion were perceived as being most favorably by the sports sector. Organizational obligations for the development of such policies were perceived as being most favorably by the health sector. Policy development: The workshops resulted in different outputs: a national intersectoral action plan (United Kingdom), a national alliance (Sweden), an integrated policy (the Netherlands), and a continuing dialogue (Germany). CONCLUSIONS: Theory-driven policy assessment and policy-maker workshops might be an important means of scientific engagement in policy development for health promotion.

Policy development and implementation in health promotion--from theory to practice: the ADEPT model.

There is a growing interest among health promotion researchers to better understand and influence the policy process. However, at this point in time, theoretical concepts enabling researchers to do so are still rare and underused, suggesting a need for new, easy-to-use concepts to explain successes or failures of health promotion policies. This article presents the ADEPT (Analysis of Determinants of Policy Impact) approach, which aims to explain and influence policy development and policy impact implementation with four determinants: goals, obligations, resources and opportunities. ADEPT provides a detailed operationalization for both quantitative and qualitative use. An empirical test of the ADEPT model using a quantitative survey of 719 policy-makers from four health promotion policy fields and six European nations indicated that both policy outputs and policy outcomes are influenced by the four determinants. The approach has, in the meantime, been successfully utilized to analyze and initiate policy development in a number of health promotion projects. Despite a number of limitations, ADEPT provides an easy-to-use, theory-based and parsimonious tool for understanding and influencing policy processes in health promotion. Moreover, as it identifies potential 'levers of influence' and can easily be connected to existing methods of community development or capacity building, it is a particularly powerful tool for policy development.

How Can Physical Activity Be Promoted Among Children and Adolescents? A Systematic Review of Reviews Across Settings.

Introduction: A vast majority of children and adolescents are physically inactive. As a result, high obesity rates and related diseases have made physical activity promotion a politically relevant topic. In order to form the basis for political decision making, evidence is required regarding the efficacy and effectiveness of interventions for physical activity promotion. In contrast to previous research, this systematic review of reviews targets three key settings (family and home, childcare, school), and is among the largest to have been conducted. Methods: A systematic review of reviews was conducted as part of a large-scale project to develop national recommendations for physical activity promotion in Germany. Six electronic databases were searched and inclusion criteria were defined. Two independent reviewers screened the titles and abstracts of potentially relevant literature. 213 reviews were identified and categorised by target group. A total of 74 reviews were identified dealing with children and adolescents. Each review underwent a quality assessment. Results: 39 reviews with the highest quality and relevance were analysed. Three reviews focused on the family and home setting, 4 on the childcare setting, 28 on the school setting and 4 on other settings. Evidence revealed the key role played by parents in promoting physical activity in children within each setting. Furthermore, evidence pointed toward the efficacy of multi-component interventions in the childcare and school setting. Several evidence-based intervention strategies were identified for childcare facilities and schools. Discussion: The review of reviews identified a number of promising strategies for PA promotion among children and adolescents. Among reviews, multi-component interventions in childcare facilities and schools stand out prominently. At the same time, the review of reviews indicated that there is still a lack of studies on the efficacy of interventions that go beyond the individual level. We recommend that future research should also target community and policy level interventions and interventions other than the school setting. In order to make more specific recommendations regarding the scale-up of promising intervention strategies, further knowledge about the effectiveness, health equity and cost effectiveness of interventions is needed.