4. Policy options to increase physical activity

Despite the recognised health and well-being benefits of physical activity, many people do not move enough. As shown in Chapter 3, eliminating insufficient physical activity would have a considerable impact on population health: if everyone in the 27 EU Member States would do at least 150 minutes of moderate-intensity activity per week, more than 10 000 premature deaths could be avoided each year, and 11.5 million cases of new NCDs would be prevented over the next three decades. Increasing physical activity would also reduce the burden on countries’ health care expenditure. If the guidelines of 150 minutes of moderate-intensity physical activity per week were met, countries would save 0.6% on average of their health care expenditure – a total of EUR 8 billion per year.

The impact of insufficient physical activity on health care expenditure presented in this report is comparable to previous estimates, albeit at the lower end of the range (Figure 4.1). Since the OECD SPHeP-NCDs model takes into account diseases and health care cost not related to insufficient physical activity (e.g. if people live longer due to increased physical activity levels, they would develop other conditions), the impact estimated by the OECD model is expected to be lower than when using a PAF approach (see also Chapter 3, Box 3.3).

It has to be noted that the benefits of increased physical activity reach far beyond population health and health care expenditure. A healthier population translates into a larger, more productive workforce. The health and economic impact of the current and potential future pandemics may be lessened (Box 4.1). Finally, there are beneficial links between physical activity policies and other important policy areas such as the environment (Box 4.2). Altogether, there is a strong case to invest in policies that increase physical activity levels in the population.

A wide range of policy options exist to increase population physical activity, including regulatory, economic and information policies. Some are setting- or target-group specific – for example interventions in schools, workplaces or in the health care setting. Other policies aim to increase access to sports facilities, or change the environment to encourage active transport and outdoor activities. Communication policies can be used to encourage physical activity and inform people about what to do, when and where (Figure 4.2). The remainder of this chapter discussed the different policy options and presents selected case studies from EU Member States.

Almost all EU Member States monitor physical activity levels in adults and children, and have physical education in schools (Figure 4.3). Moreover, since 2015, there has been a strong increase in the number of countries that have policies to improve access to physical activity for socially disadvantaged groups and older adults, and schemes for physical activity promotion in schools and the workplace.

However, there is still considerable scope to expand the policy response across the Europe. In particular, few countries have implemented programmes to involve sports clubs in health promotion (Sports Clubs for Health, see also Box 4.6), or systematically apply the European guidelines in planning leisure-time infrastructure (IMPALA, see also Box 4.8). Schemes to promote active travel to school or work are only present in 14 and 17 out of 27 EU Member States, respectively. Moreover, while in 2015 all countries reported having a HEPA policy or action plan that specifically targets high needs groups (e.g. young children, older adults people in low socio-economic groups, people with a disability), in 2021 only 20 out of 27 countries had such policies.

Schools can play an important role in increasing physical activity, by providing education on the importance of physical activity as well as by offering physical activity opportunities during and after school. Physical education classes have been shown to make students more active in, outside, and beyond school, as well as having a positive effect on students’ social skills and social development (OECD, 2019[12]). It may also improve educational outcomes (Norris et al., 2019[13]) and contribute to healthy lifestyles that last into adulthood (Dohle and Wansink, 2013[14]; Black et al., 2019[15]). In all EU Member States (WHO, 2021[11]), schools are required by law to provide physical education classes.

However, there is considerable variation in how physical education is defined and quantified, how it relates to and encompasses health education, how it is inscribed and regarded within the curriculum, and, importantly, how it is implemented and assessed in schools (OECD, 2019[12]). While all EU Member States reported having physical education classes, only 74% monitored their quality (WHO, 2021[11]).

Besides physical education classes, physical activity can also be encouraged in schools through targeted programmes (Box 4.3). In the EU, programmes to encourage active school breaks have been implemented in 12 countries, active breaks during lessons in 16 countries, after-school physical activity programmes in 21 countries and programmes to encourage active travel to school in 14 countries (WHO, 2021[11]).

As many adults spend a large portion of their lives in the office, workplace-based actions are increasingly considered as an effective tool to influence lifestyle (OECD, 2019[20]). Actions can target behaviour in the workplace, such as reducing sedentary behaviour by encouraging walking breaks and stair use, or focus on transport to and from the office (Box 4.4). In 2021, 20 out of 27 EU Member States had national guidance or a programme to promote physical activity in the workplace, and 17 had national guidance or a programme to promote active travel to work (WHO, 2021[11]).

Interventions to reduce sedentary behaviour are of particular importance for desk-based work environments, where employees spend a large part of their day being sedentary. These interventions can be educational strategies, such as counselling, behavioural strategies, like point-of-decision prompts to take the stairs, or environmental strategies, such as standing desks (Chu et al., 2016[21]).

Previous OECD modelling estimated that implementing programmes to combat workplace sedentary behaviour in 36 countries could prevent 232 000 cases of cardiovascular disease and 222 000 cases of diabetes over 2020-50, and increase GDP by 0.015% (OECD, 2019[20]). Moreover, due to the positive impact on health care expenditure, workforce size and productivity, for every EUR 1 invested in workplace sedentary behaviour programmes, EUR 4.1 is returned in economic benefits.

Health care professionals are well placed to provide advice on physical activity and its health benefits, as their opinion is generally respected and they come into contact with a large proportion of the population – including high-risk groups. Such advice can take the form of general behavioural counselling, or more formal prescribing of physical activity (OECD, 2019[20])(Box 4.5). In the EU, 18 out of 27 EU Member States had national guidance or a programme to promote counselling on physical activity or exercise prescription by health professionals in 2021 (WHO, 2021[11]).

The basic model of physical activity on prescription (PAP) programmes includes a personalised written prescription detailing the type, amount and intensity of physical activity. This prescription is takes into account the person’s health status, motivation and preferences. However, the design of PAP programmes varies across countries and regions: prescriptions can be written by GPs, nurses or other health professionals; the prescribed physical activity can be facility or home-based; and the programme duration differs (OECD, 2019[20]). Importantly, frequent meetings as well as subsidised or free access to sports facilities or exercise classes can improve the effectiveness of the programme, but also increases the cost.

Previous OECD modelling estimated that implementing PAP in 36 countries would prevent 236 000 cases of cardiovascular disease and 96 000 cases of diabetes over 2020-50 and increase GDP by 0.006% (OECD, 2019[20]). Moreover, for every EUR 1 invested in prescription of physical activity programmes, EUR 0.9 is returned in economic benefits – on top of the health and well-being benefits.

Sports facilities can play a major role in enabling and encouraging physical activity in the population (Box 4.6). Increasing public spending on recreational and sports services can increase the physical activity level for the population. OECD modelling estimates that, for Italy, an additional 1% investment could avoid more than 800 cases of cardiovascular disease annually, and it would be highly cost-effective (less than EUR 30 000 per DALY) as early as five years after the beginning of the intervention (Goryakin et al., 2019[29]).

Availability of and access to sports facilities is an important drivers of physical activity: 82% of people who exercise or play sports regularly say that they have many opportunities to do so in their local area, compared to 66% of people who never exercise (European Commission, 2018[30]). Opportunity is linked to socio-economic factors, as 79% of people who pay their bills without difficulty agree that they have sufficient opportunities in their area, but this falls to 59% among people who have difficulties paying bills most of the time. To ensure equitable access to sports facilities, such as sport pitches or gyms, they need to be available in the community, for people of all ages and abilities, at an accessible price.

Physical activity is not just structured exercise and sport, but includes activities such as outdoor playing, recreational hiking and cycling to work. Urban design and the environment can facilitate these forms of physical activity by providing safe and pleasant spaces to move. Environmental policies to encourage physical activity can include regulation to improve road safety, urban planning requirements to increase parks, trails and other green spaces, and investments in dedicated cycling and walking lanes and other infrastructure.

One example is investing in public transport. Building new public transit options is estimated to increase the light to moderate physical activity of users by about 30 minutes per week, as people walk or cycle to transit stops (Xiao, Goryakin and Cecchini, 2019[33]). OECD modelling has shown that, on a population level, this can prevent 121 000 cases of cardiovascular disease and 37 000 cases of diabetes over the next 30 years across 36 countries, and raise GDP by 0.004% (OECD, 2019[20]). Transport policies can also focus on cycling (Box 4.7) and walking as active modes of transport.

Design guidelines can help local governments and developers to create spaces that enable and encourage physical activity. The IMPALA guidelines were developed in Europe to support the development and improvement of infrastructure for physical activity (see Box 4.8). In 2021, only five out of 27 EU Member States reported that they applied the IMPALA guidelines systematically (WHO, 2021[11]). However, another 13 countries reported that they used similar national guidance or programmes.

The first action of the WHO Global action plan on physical activity 2018-30 (WHO, 2018[37]) is to implement communication campaigns to increase awareness, knowledge and understanding of, and appreciation for, the multiple health benefits of regular physical activity. However, the messaging should not be limited to the health benefits, but also highlight the social, economic, and environmental co-benefits. Moreover, messaging should be inclusive, with images tailored to the diversity of communities (WHO, 2021[38]).

In 2021, 23 out of 27 EU Member States reported to have clearly formulated national campaigns for education and public awareness about physical activity (WHO, 2021[11]). While television, radio and newspapers remain commonly used media, 21 countries also reported using social media. However, while public awareness campaigns are an important part of any physical activity strategy, there are other information policies that can help promote physical activity, such as apps to locate resources (Box 4.9).

While all policies have their own benefits, it is unlikely that any single policy will have a major impact on physical activity levels in the population. Physical activity is a complex behaviour, which is influenced by many different factors, including personal variables such as motivation and physical ability; environmental factors such as schools, worksites, and other places where people spend most of their time; community characteristics determining the opportunity to exercise, as well as social factors such as peer pressure and public information (Bauman et al., 2012[40]). To increase physical activity, a comprehensive package of policies is needed to target all of these factors at the same time.

Previous OECD modelling work has shown how a physical activity policy package including interventions such as prescribing physical activity, investing in active transport and school-based programmes can lead to significant health gains and savings in health care expenditure. Such a package of policies aimed at increasing physical activity, implemented in 36 countries, would prevent 38 000 NCDs per year and save around EUR 14 billion in health cost by 2050 – equivalent to the total annual health care expenditure of Greece. Moreover, for every EUR 1 invested in a physical activity policy package, EUR 1.7 are returned in economic benefits (OECD, 2019[20]).

As with any public health strategy, it is crucial to ensure that the policy package has both financial and political support. Current funding for physical activity is often insufficient, short term, narrow in scope, and focussed on pilot and demonstration projects instead of strengthening a supportive system. Policy makers should set up sustainable and long-term funding (Box 4.10) (WHO, 2021[38]).

Moreover, while multicomponent, multilevel strategies are notoriously difficult to study, a comprehensive evaluation should be conducted to help understand whether the strategy works, what other impact it has, its value relative to the resources required to deliver it, how it interacts with the context in which it is implemented, and how it contributes to system change (Skivington et al., 2021[42]). An efficient data management and data linkage system to collect timely and accurate data can support evulation studies (Box 4.11).

The task at hand is clear: make physical activity a public health priority to improve health and reduce the burden of non-communicable diseases. However, to achieve such a goal, much work remains. Rather than falling under strategies for other risk factors, physical inactivity should be a separate and equal concern, and should be recognised as a unique specialty. A strong policy framework, consistent investment in physical activity programs and infrastructure, multi-sectoral support, high population reach, and good surveillance should characterise each future action (Pratt et al., 2015[44]). Adaptation of the evidence-based strategies to community need, culture, and context is critical. An isolated public health strategy for physical activity is unlikely to be successful as many of the necessary actions occur in sectors other than public health and because sustained funding is nearly impossible without the broader political support associated with strong partners.


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