Figure 1 presents an overview of the typology and of the examples for the position of select documents within the matrix. The following sections provide short descriptions of the characteristics of each field, its relation and delineation from other fields, and the example used to illustrate it.
Documents related to individual physical activity and health
The first column of the typology contains documents that are related directly to individual physical activity, and that are usually based on evidence that links physical activity to health outcomes [7]. Field 1 would consist of the “classic” recommendations based on expert consensus about how much physical activity individuals should engage in to maintain or improve their health. One well known example are the “150 minutes of moderate-intensity exercise per week” [16], published as “guidelines”, “guidance”, “position statement” or “recommendation” by the American College of Sports Medicine (ACSM) [1, 16,17,18,19]. Statements of ACSM have usually been highly influential for the subsequent development of the field on a global scale, but they have never been binding for American citizens, doctors or administrations at the local, state or federal level.
A prominent example for Field 2 are the WHO Global Recommendations on Physical Activity for Health [5]. Like ACSM, this document recommends at least 150 min of moderate to vigorous physical activity per week for healthy adults, with additional recommendations for children, adolescents and older people. Documents of Field 2 have the same perspective and goals as recommendations placed in Field 1, but we argue that the fact that they were published or officially endorsed by a national or international public organization gives them a higher degree of political clout.
For physical activity, Field 3 constitutes an almost “hypothetical” category, as there are much fewer laws and regulations – unlike, for example, in the areas of tobacco control (smoking bans), alcohol use (restriction of sale to minors). Documents formally regulating individual physical activity do exist, but only in closed environments: Public organizations such as armies, police forces and fire departments prescribe fitness levels or specific regular physical activities for their forces and enforce them through various means. For example, the US Army requires all its active soldiers to take the Army Physical Fitness Test twice a year and to score a minimum of 180 out of 300 points; failing the test consecutively may lead to exclusion from the force [20].
Documents related to physical activity interventions
The next three boxes of the matrix are not directly related to the question of optimal individual physical activity levels but to collective action to promote physical activity, i.e. to “evidence that links interventions to physical activity behavior” [7] (category II). This evidence comes from the large body of research conducted on the effectiveness of different types of physical activity interventions. The goal of documents in the second column of the typology is to recommend (with varying degrees of coercion) “good” or “best practice” interventions to increase physical activity levels in the population.
Field 4 might contain documents originating from scientific projects that select suitable interventions for the general population or specific age and target groups and showcase them to policy-makers and professionals in order to provide inspiration for implementation in additional places or settings. These documents have in common that they do not come from public institutions and therefore have a low degree of coercion; instead, they act as “a source of inspiration, learning and practical guidance” for practitioners and health promotion organizations [21]. As an example, “Investments that Work for Physical Activity” [22] (sometimes also referred to as “The 7 Investments” for short) highlights good practice interventions in schools, transport, urban design, health care, public education, community and sport for all. It accompanies the Toronto Charter [23] (see Field 7 below) and was published by the Global Advocacy Council of the International Society for Physical Activity and Health (ISPAH) – a membership organization for researchers, practitioners, and policy-makers.
Recommendations by national governments or international organizations on interventions to promote physical activity in different sectors or for different age and target groups would fall into Field 5. These documents arguably have a higher degree of coercion as they come from “official” organizations with a considerable reputation and high level of visibility. However, they are non-coercive in that they do not “force” physical activity promoters to utilize the recommended interventions. A prominent example is the WHO report “Interventions on Diet and Physical Activity: What works” [24], which systematically reviewed the available scientific evidence for interventions in eight different categories and made recommendations based on a quality ranking.
Field 6 pertains to “recommendations” for physical activity interventions that have a highly compulsory character, i.e. that are actually enforceable. Theoretically, governments (esp. at the national level) could prescribe certain interventions to organizations active in physical activity promotion, similar to regulations on food labeling or formulation in the area of nutrition or on advertising for tobacco and alcohol. They tend not to do this, but again, examples for such a mechanism exist in more limited environments (as in field 3). The “Leitfaden Prävention” (Prevention Guideline) of the German Health Insurance Association stipulates a set of criteria that interventions must meet in order to become eligible for reimbursement by the semi-public German sickness funds, i.e. sickness funds may only conduct or subsidize interventions that meet these criteria. Independent providers have to prove the eligibility of their offers to a central certification body. Insured persons engaging in approved courses can submit a certificate of participation to their sickness fund and claim partial or full reimbursement for their program fees [25].
Documents related to physical activity policies
The third column of the matrix (Fields 7, 8 and 9) covers physical activity policy. It is based on research evidence for effective physical activity policies (category III). “Policy” has been defined as “legislative or regulatory action taken by federal, state, city, or local governments, government agencies, or non-governmental organizations such as schools or corporations” [26]. Research into effective policies could, for example, try to assess whether intersectoral government action is more effective in increasing physical activity levels than actions directed by a single sector. As with the other two categories of evidence, there is a continuum between recommendations with a low degree of coercion, usually published by experts or advocacy organizations, and highly binding documents, usually national policies. For the purposes of this typology, we suggest to limit our scope to public/government policy. One reason is that public policy constitutes the bulk of this category; another is that organizational policies (e.g. school policies) often tend to be confounded with interventions and are often reported as part of category II evidence [7].
A suitable example for Field 7 is the Toronto Charter [23]. Published alongside “Investments that Work for Physical Activity” (see Field 4), the Charter is the more general, strategic document of the two. It argues for the need to address four key areas: national policies and action plans, policies that support physical activity, funding for physical activity and a corresponding reorientation of services, and partnerships for action. As it was authored by the Global Advocacy Council of ISPAH, the Charter has a relatively low degree of coercion and is not politically binding in any way.
Some WHO Strategies seem to fall into Field 8 of the typology. A prominent and recent example is the Global Action Plan on Physical Activity [3]. On the one hand, such documents are much more “compulsory” than any policy recommendation issued by expert or advocacy groups. They are formally adopted by Member States, and all signatories commit to their implementation to a certain degree. However, these documents do not stipulate any specific compulsory goals to be reached by Member States, nor specific measures to be taken. Instead, they mostly “suggest” possible courses of action that countries may choose to either adopt, adapt or choose not to implement based to their specific national context.
Field 9 would typically be populated by national physical activity promotion documents such as the “Sport 2030” plan by the Australian Federal government [27]. This recent policy stipulates that the government will introduce programs to reduce barriers to participation in physical activity, fund sport organizations and other partners to promote physical activity, and coordinate activities with sub-national governments and non-governmental organizations. Since it is officially published by the government itself, such a document has a much more politically binding character for national policy-making than the documents in fields 7 and 8, which a country can either opt out of or even disregard altogether.
Documents on the boundaries: horizontal or vertical overlaps
Two final examples show that some documents do not clearly fall into one of the nine types but ‘sit on the boundaries’ between them or may partially ‘reach’ from one field into another horizontally (i.e. between categories/columns) or vertically (i.e. between degrees of coercion/lines).
A typical example for a horizontal overlap are the German National Recommendations for Physical Activity and Physical Activity Promotion [28], which may be filed into Fields 2, 5, and 8 of the typology. Developed by a team of experts but officially tendered, endorsed and published by the Federal Ministry of Health, one can consider the document to have a medium degree of coercion. But as the name suggests, it covers both category I and II (i.e. recommendations for individuals and for appropriate interventions), and even extends into category III in several places by suggesting specific policy action (including intersectoral coordination, transport regulation, and fiscal incentive mechanisms).
A document situated vertically between the different degrees of coercion is the European Council Recommendation on Health-Enhancing Physical Activity across Sectors [4]. It is a policy document that exerts less political influence than a national policy (Field 9) but far more than typical documents from Field 8. The reason is that its originator, the EU, is a supra-national organization with far greater leverage on its member states than international organizations such as WHO [29, 30]. EU Member States will not face direct sanctions if they fail to implement the recommendation but may be exposed to peer pressure by other governments. In addition, the document obliges the European Commission to invest resources to support implementation and monitoring, increasing the chances for a potential impact of the document on national policy-making.