An evaluation of equity and equality in physical activity policies in four European countries

This study was conducted as part of the ‘Research into Policy to enhance Physical Activity (REPOPA) project within the European Commission’s FP7 funding framework [22, 23]. The study aimed to gain an insight into the consideration of equality and equity issues and of vulnerable groups in selected PA policies. The study included PA policies from four REPOPA countries, Denmark, Finland, Romania and England. Content analysis of selected policy documents was conducted followed by stakeholders’ interviews to identify if equity and equality issues were considered in the selected policy documents.

The REPOPA project aimed to integrate scientific research knowledge, expert know-how and real world policy making process and to have academic institutions producing evidence as collaborating partners. Also, the project included organisations involved in the development and implementation of public health policies, as this was seen as an important component in the process of to bringing in their interests, values and priorities (Table 1). Further, to understand cultural and other contextual challenges, collaborating partners for this study came from four European countries representing different European regions [for further details see 22,23]. In each of these four countries, a national research team selected at least one local, regional and national PA related policy, if available, conducted documents analysis and stakeholder interviews following a commonly agreed protocol and reported the results.

Fourteen PA policies from four European countries (Denmark, Finland, Romania, and England) were included for analysis in this study. The policies focused mainly on PA, health, transport, nutrition and regional or local development, including health and physical activity concerns. The responsible authorities for these policies were ministries and regional and local authorities, in cooperation with various stakeholders.

The aim of the selected policies was to increase physical activity of the overall population (and/or of specific population groups) in order to enhance health. To tackle the inactivity, various specific behavioral and promotive actions were planned in various contexts and environments. Table 1 presents the titles of the policies, the main responsible authorities for each policy and the timeframe for implementation, as well as the overall vision and objectives of the policies.

Through document analysis we identified the policy themes, such as the level of the policy, the focus of the policy, and target of the policy in relation to equity and equality towards various population sub-groups. Given the complex processes of policymaking, it was decided to carry out a content analysis of the policy documents followed by stakeholders’ interviews. This two-step approach was done to first identify how inequity and inequality issues were integrated into policymaking processes and then to discuss and confirm identified issues during interviews.

Purposeful sampling was used to identify and select interviewees. This involved identifying and selecting individuals who were especially knowledgeable about or experienced with PA policy making within the policies included in the analysis [23‐25]. A total of 61 stakeholders were interviewed (Denmark 17; Romania 11; England 12; and Finland 15 stakeholders). Interviewees were policy makers, researchers, public sector officials and other influential stakeholders who were directly involved in the policy making process of the policies selected for analysis. Interviewees were contacted by the national research teams and provided with basic information on the project. Consent forms were administered in national languages of the partner countries. Semi-structured interviews were undertaken to further explore the equity and equality issues in PA policies, using a common interview guide across all participating countries [23]. The interviews were conducted by researchers from the respective countries in their native language. Each interview had a duration of 60 to 90 min and where additional consent was granted, the interviews were audio-recorded (notes were taken if this consent was not given). The interviews were then transcribed [23].

In the content analysis stage, the policy documents were reviewed by the REPOPA country teams to identify equity and equality issues. This also gave an opportunity to identify broader political forces (for example stakeholder positions) influencing policy decisions and to define how equity and equality issues were considered in the policy making process.

The content analysis of PA policy documents and the interviews followed the approach of Ritchie and Spencer [26], which is focused on case and theme based approach. The analytical tool uses a framework, which follows interpretation approach by ordering data and involving thematic analysis, typologies and explanatory analysis. The REPOPA team prepared a common content analysis guideline of policy documents to be used by all partners. The common guideline covered the policy-making phases; selection of policies; the process description of the policy analysis and instructions for the PA policy analysis; the focus of analysis in relation to goals and processes; a schematic example of the analysed text of a policy as well as equality and equity and population groups.

Thereafter, the findings were reported in English and pulled together into one report. The implementation phase of the policies was not included in the analysis, as it was out of the scope of the study.

Ethical clearance was obtained in accordance with the requirements of each country. The REPOPA Coordinator developed an Ethics Road Map and Ethics Guidance Document to coordinate varying national ethics clearance procedures in partner countries. Ethics clearance was done in each country according to country-specific regulations and procedures (for details see [27]). Irrespective of the country requirements, the informed consent of all participants was obtained. Ethical Committees involved per country: Ethics Committee of the Region of South Denmark and the National Data protection Agency; Research Ethical Committee of the National Health and Welfare Institute in Finland; Ethics Committee of the University of Babes-Bolyai in Romania; and the Ethics approval by the Research Councils in England. The ethical clearance papers were approved by the European Commission before the start of the project. The European Commission had oversight of the whole project ethics.

The analysis included six national policies (one from the England, three from Finland and two from Romania), three regional policies (one from Denmark, Finland and Romania) and five local policies (one from England and Finland and three from Denmark) (Table 2). The analyzed PA policies differed in their style of presenting health equity and equality on national, regional and local levels, as the purpose of each policy was not necessarily focused on inequities or inequalities. Nevertheless, the policies served similar functions in their contexts, most of them representing examples of symbolic policies that may eventually lead to political initiatives and implementation programs.

PA policies analyzed presented how governments wished to express their concerns and intentions related to PA promotion in the population. In policies focused on health promotion, the main concerns were the achievement of population health outcomes, which could be influenced by how the health system was organized and funded, but mostly by enabling people to expand their capabilities and develop self-reliance in health and health promoting behavior (Table 1). This encompassed places where people lived, such as local communities, homes, workplaces and playing fields, and people’s access to resources for health, and opportunities for empowerment.

In the analyzed PA policy documents various subgroups were considered as policy targets. Such groups included children (preschool, school age children), young people (teenagers, students), professional groups (teachers), older people and other specific groups (psychiatric patients; people with disabilities; rural residents; immigrants; the unemployed; the poor) and the private sector as collaborating partner in the PA policy process.

Our study looked at the target groups of various policies, with different main focuses (e.g. health promotion, physical activity, transportation) and at different levels (e.g. national, regional, and local). The results showed that the target groups of the policies varied and that the countries and policies were not comparable. The study presented a picture of how policies can focus on certain groups of people or alternatively approach a whole population to promote PA. The transport policies and Olympics policy focused on the many ways to arrange PA possibilities and provide opportunities to citizens to be active and continue their activities during their life span, whereas the other policies analyzed were more focused on the public health sphere to encourage PA.

When looking at equity and equality issues in the policies, we looked at how the terms were mentioned as preconditions for health, specifically for low socioeconomic groups and for people with low education level, as well as the aims to provide possibilities to achieve better health through PA.

In the Danish language, equality and equity are terms that are used in parallel. In the Danish policies analyzed equality was used as an overall term. In Denmark, in the policy for the region of Zeeland, equality was not discussed. However, due to the relatively large geographical size of the region (containing 17 of the 98 Danish municipalities) differences in the level of education, income, and health across the region were mentioned as an issue of concern. In the policy concerning the city of Copenhagen, variations in inequality in health across districts were mentioned. The focus on inequality in health, and also in PA, was a part of the “Long Live Copenhagen” policy document, which presented several arguments to support the importance of focusing on equality in health, though without any references to support the arguments. The policy emphasized the importance of initiatives targeting citizens living in districts with a high proportion of residents with unhealthy lifestyles, sickness and ill‐health. The interviews confirmed that with the support of health centers in low resource districts, initiatives were developed to target Copenhageners who do not reach out for help regarding their own situation. Examples of initiatives delivered at the health centers were consultations about exercise, strengthening of social networks, and the creation of opportunities for play and movement. The purpose of such initiatives was to create more equality in public health, by significantly improving the health of Copenhageners in districts with a high level of inequality in health. In most cases managers and politicians decided that inequality across geographical areas should be highlighted.

In Odense, Denmark, equality issues regarding PA were particularly recognized in the goal of the policy document concerning urban spaces. Urban planning was aimed at enhancing physical activity among all citizens by increasing accessibility, active transport, green areas and diversified activities in a safe and informal public space, as well as in deprived neighborhoods. On the long run, the municipality hoped that a healthy framework will decrease lifestyle-related diseases among citizens. Equality in access and opportunities for healthy living could narrow inequality in health. Creating a publicly available framework for a healthy lifestyle was stated in the goal; “the easy choice is the healthy choice”, and contained elements that promote equality for PA. This latter goal specifically mentioned children and youth as an essential group to focus on, because healthy habits are often adopted in childhood. No direct reference to research evidence was presented that justified the chosen goals and subgroups. One of the main goals “greater equality in health” in the health policy stated support for the equity issue. Inequity in health is one of the political goals, which was considered both strength and a challenge.

In Esbjerg, Denmark, the policy itself did not mention equality. However, according to one interview with a politician, it was stated that politicians agreed to uphold and distribute equality and fair conduct to all. Nevertheless, the interviewees confirmed that, during the policy process, there were discussions on equality. For example, in the Sport and Physical Activity Policy it was discussed whether to select a life cycle approach, and how to include a variety of stakeholders in the policy-making phase and in the implementation phase. The life cycle approach was not integrated into the final policy due to resistance from the local sports clubs, who were the primary stakeholder, since they were not able to translate this approach into their own organizational objectives.

In Finland, in the sport and PA policy document it was emphasized that sport policy should promote the wellbeing, health and functional capacity of the population at different stages of life with an emphasis on child and youth sport. The aim was to strengthen the prerequisites of local activity, inclusive equality and the position of sports as a basic local service. The sport and PA policy underlined that everyone should have equal opportunities to pursue a sportive way of life and to gain positive experiences and a sense of communality through sports and PA. The arguments for equity were joy of life, health and wellbeing, and functional capacity at different stages of life; emotions and shared experiences; having equal opportunities, experiences and a sense of communality. In addition, the policy stated that the public sector offered motivations and promoted equality in sports, while NGOs promoted the idea of social capital and active citizenship through their actions. The public sector measures were geared to influencing the underlying reasons for physical inactivity, to support citizens’ choices in PA and to promote equality. Society, communities and individuals should commit to a shared vision of the potential of sport as a factor for wellbeing, incentives targeted to certain population groups, and full consideration of regional, linguistic and gender equality. However, no specific research evidence or budgetary allocation for these choices was presented.

According to interviewees in Finland, equity was reflected in all the policy issues as the responsibility of the public sector to produce equal and achievable services for all. However, it was admitted that taking equity into consideration was different depending on the municipality, with different levels of formal concern and different activities among the actors regarding equity. Also, equity was understood to mean that when taking into account the whole population, one actually does not pay attention to any particular person or group. One interviewee stated that “It seems that sports have ‘higher-middle-class features’ as the general population does not have enough funds to take part in sports through the sports associations. Sports became a question of economic status.” According to the interviewees, lack of PA and sports have intensified the economic polarization between population groups.

In Finland, Health Enhancing Physical Activity (HEPA) and nutrition policy specifically underlined the reduction of health inequality differences between population groups. The main concern mentioned in interviews was that the schools and student health services were expected to ensure that youth are in an equal position irrespective of their municipality of residence and the education institution that they attend.

In the Finnish Walking and Cycling policy, equity was mentioned as economically advantageous choices for individual citizens. Walking and cycling were considered to promote people’s equal possibilities for mobility and equality, particularly among those who do not drive a car. Based on interviews, equity was discussed and considered to be a self-evident issue in the policy making process. However, the policy was aimed at making walking and cycling equal to other modes of transportation and at enabling everyone the right to walk and cycle in equal circumstances.

In Finland, the policy of the Päijät-Häme region referred to equality in constructing pedestrian and bicycle routes, commuting safely to school or work by foot or bicycle and providing people with opportunities to exercise in their leisure time. Furthermore, pedestrian and bicycle routes were considered to promote safe outdoor activities for older persons. Pedestrian and bicycle routes were considered as local sports venues, which were suitable for almost anyone and would increase equality and interaction between people. According to interviews, people in lower socioeconomic groups should get PA close to their everyday life to prevent isolation and loneliness.

The policy of the City of Lahti did not mention equity or equality issues specifically. Some differences (especially between men and women) in the amount of PA inside subgroups were presented. Interviewees stated that equity was internally structured in policy and that it was discussed as a principle that everyone should have a possibility to access and participate in PA services.

In Romania, in the Movement for Health national policy, equality and equity issues and research or other evidence to legitimate these problems were not presented at all in the policy document. Although preschool children and (pre-university) students were addressed separately by the policy, they were not defined as vulnerable groups. According to the interviews, generally, in the policy making process, other types of evidence such as population preferences, traditions, as well as resources available at local level were the most important contributing factors in choosing the target groups. No scientific data was used to support the need for targeting these population subgroups (in relation to other population subgroups). Also, given the fact that the main purpose of this national policy was to develop sport infrastructure (i.e. 400 sport halls throughout the country), it is not clear, from the policy documents or the interviews, what arguments underpinned the decision regarding where these sport halls were most needed-in terms of equity and equality or in terms of access.

In Romania, the national policy Sport for All-Romania 3^rd Millennium, a Different Lifestyle did not mention specific equity or equality issues in the policy description. However, in the methods sections of the policy document it is stipulated that the subprograms will be “elaborated for different population structures taking into consideration the following indicators: age, occupation, ethnicity, deprived groups [no definition and types of deprived groups are included], diaspora”. No mentions were made in regards to the evidence behind choosing these specific population subgroups as targets for the subprograms, nor were these subgroups presented as vulnerable populations. In the interview phase was found that the target populations for this national program were chosen after considering the research evidence gathered from “The fitness potential of the population” study. The study was conducted nationally by the Ministry of Education within the school-aged population (although no specific results from this study could be identified in the policy document or during the interviews). As well other types of evidence, such as population (expressed) needs, previously implemented programs, on-site observations were used in the policy making. Different age groups, disadvantaged population subgroups, such as those in rural areas, have been thus considered. One of the interviewees mentioned that “Information from the territory regarding needs and problems, as well as a technical analysis” have contributed to the choice of the target populations needed for each of the subprograms of this national program.

In Romania the county (regional) policy Cluj Champions-The protocol for organizing sport activities for children in Cluj County did not mention equality and equity issues in the policy document. Based on the interviews with stakeholders, the urban/rural and male/female criteria, and with or without physical or mental disabilities, were considered when developing the activities to be organized in the implementation phase of this partnership policy (i.e. sport competitions for school-aged children on different sport branches were organized as a result of this partnership between the County Council, the County School Inspectorate and the County Youth and Sport Department). Hence, the planned competitions included boys and girls from urban and rural areas from Cluj County, with and without physical and mental disabilities. Of course, there were separate competitions organized for each of the aforementioned population categories, with the exception of urban/rural, which participated in the same competition for each sport branch (e.g. football, athletics).

In England, the Places People Play program did not present equity issues, except in regard to equity between male and female in some target groups. In England, the Herefordshire transport policy did not make reference to equity or equality issues, but mentioned improving conditions for vulnerable road users e.g. people with disabilities and children. The needs of the dispersed rural population and increasingly older population were also mentioned.

None of the policies included into the analysis explicitly mentioned the issues of reaching equality and equity as on the policy focus. Most of PA policies analyzed in this study focused on the whole population and targeted one or more subgroups in more specific policies. To reach low socio-economic groups and provide equity in access to PA services requires more focus on longer term programs in PA to have an impact. Many of the policies are in force and implementation has been pending on elections and political powers in the government. However PA promotion is not pending on political changes, but lifetime encouragement and creating environment and culture for active lifestyle to bring the monetary and human resource savings for the societies.

None of the policies specifically addressed equity and equality in PA in relation to population groups, services or interventions. However most of the policies had some components of equity and equality in the policy documents, but they were not specifically underlined as such. Even some of the policies that did not mention equity and equality were reported to be discussed in the policy development process or in the programs for implementation. Though equity and equality were not directly addressed, they were considered to different extents in different contexts in Denmark, Finland, England and Romania.