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Tremblay, Mark S and Gray, Casey E. and Akinroye, Kingsley K. andHarrington, Deirdre M. and Katzmarzyk, Peter T. and Lambert, Estelle V.
and Liukkonen, Jarmo and Maddison, Ralph and Ocansey, Reginald T.
and Onywera, Vincent and Prista, Antonio and Reilly, John and del Pilar
Rodriguez Martinez, Maria and Sarmiento, Olga L. and Standage, Martyn
and Tomkinson, Grant R. (2014) Physical activity of children : a global
matrix of grades comparing 15 countries. Journal of Physical Activity
and Health, 11 (Supp 1). pp. 113-125. ISSN 1543-3080 ,http://dx.doi.org/10.1123/jpah.2014-0177
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Journal of Physical Activity and Health, 2014, 11(Supp 1), S113-S125
http://dx.doi.org/10.1123/jpah.2014-0177© 2014 Human Kinetics, Inc.

Official Journal of ISPAH
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 inluencing 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 Environment, 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
indings are summarized here in the form of a global matrix of grades. There is a large spread in grades across countries for mostindicators. Countries that lead in certain indicators lag in others. Overall, the grades for indicators of physical activity (PA) aroundthe world are low/poor. Many countries have insuficient 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 wasa pattern of higher PA and lower sedentary behavior in countries reporting poorer infrastructure, and lower PA and higher sedentary behavior in countries reporting better infrastructure, which presents an interesting paradox. Many surveillance and researchgaps 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
Physical Activity for Children and Youth1,2 has been effective inpowering the movement to get kids moving by inluencing priorities, policies, and practice in Canada.3 Details of the developmentof the AHKC Report Card and its impact have been previously
described.1–5 The AHKC Report Card was designed to serve as aknowledge translation instrument, aimed at increasing and accelerating the dissemination of research, practice-based evidence andevidence-based practice through effective and strategic synthesis,
exchange, mobilization, and application of knowledge while
facilitating interactions among researchers and knowledge users.6,7
The AHKC Report Card has served as an advocacy mechanism
to drive social action by stimulating debate, motivating policy,
practice, and behavior modification and inspiring change in
Canada.1–3

In response to growing international concern over childhood
physical inactivity, AHKC (www.activehealthykids.ca) hosted a
Global Summit on the Physical Activity of Children in May of
2014.8 The Summit brought together researchers, practitioners,
policy-makers, and funders from the physical activity (PA), sport,
recreation, education, itness, transportation, early childhood development, public health, and medical sectors from across the globe.
A highlight of the Summit was the presentation of Report Cards
from 15 countries,1,9–22 which were modeled after the AHKC Report
Card,1,2,4,5 adapted to each country’s local or speciic context, andfollowed procedures that were harmonized with the Canadian process.1,2 Details of the process in each country are briely describedin this issue of the Journal of Physical Activity and Health.1,9–22
This paper consolidates indings from the 15 countries, creating
a “global matrix” of common indicators graded by each country

Tremblay (corresponding author: mtremblay@cheo.on.ca) and Gray are with
the Healthy Active Living and Obesity Research Group, Children’s Hospitalof Eastern Ontario Research Institute, Canada. Akinroye is with the Nigerian
Heart Foundation, Lagos, Nigeria. Harrington is with the Diabetes ResearchCentre, University of Leicester, Leicester General Hospital, United Kingdom.
Katzmarzyk is with the Pennington Biomedical Research Center, Baton Rouge,
LA. Lambert is with the MRC/UCT Research Unit for Exercise Science andSports Medicine, Dept of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa. Liukkonen is with the Dept of Sport Sciences,
University of Jyvaskyla, Finland. Maddison is with the National Institute for
Health Innovation, University of Auckland, New Zealand. Ocansey is with theActive Lifestyle and Wellness Association Ghana, Healthy Active Kids-GH,

Ghana. Onywera is with the Dept of Recreation Management and Exercise
Science, Kenyatta University, Nairobi, Kenya. Prista is with the Physical
Activity & Health Research Group, Research Center on Sports Development
and Physical Activity, Universidade Pedagógica, Maputo, Mozambique. Reilly
is with the Physical Activity for Health Group, School of Psychological Sciences and Health, University of Strathclyde, Scotland. Rodríguez Martínez iswith the Instituto Tecnológico de Estudios Superiores de Occidente (ITESO),
Jalisco, México. Sarmiento Duenas is with the Dept of Public Health, Schoolof Medicine, Universidad de los Andes, Colombia. Standage is with the Dept
for Health, University of Bath, United Kingdom. Tomkinson is with the Healthand Use of Time Research Group, Sansom Institute for Health Research,
University of South Australia, Adelaide, Australia.
S113

S114

Tremblay et alusing the best available evidence in their jurisdiction. The global
matrix not only assesses global variation in indicators related to PA,
but also serves as a tool to motivate change, facilitate advocacy, andcross-fertilize efforts aimed at empowering the movement to get kids
moving around the world.

Global Matrix Participants and Procedures
Plans to engage countries to participate in the Global Summit on the
Physical Activity of Children began in 2012. Through individual contacts, word of mouth, the International Study of Childhood Obesity,
Lifestyle, and the Environment principal investigators,23 and Internet
notices, researchers were encouraged and coached to develop a Report
Card for their respective countries for release or presentation at the
Global Summit. Three countries (Kenya, Mexico, South Africa) completed their Report Cards for the second or third time. The generalprocess for developing a Report Card included the aggregation andconsolidation of the best available evidence and information synthesized
into public facing, policy-focused, and research-based outputs, mostnotably 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 madea priori to condense the indicators to 9 for the purpose of the global
matrix comparisons. The indicators included 5 behaviors: Overall
Physical Activity, Organized Sport Participation, Active Play, Active
Transportation, Sedentary Behavior; and 4 key inluences: Family andPeers, School, Community and Built Environment, and Government
Strategies and Investments. The grading framework and benchmarksthat guided the process of assigning a grade to each indicator are provided in Tables 1 and 2, respectively. Because the quality and quantityof data and evidence available in each country varied substantially,
the benchmarks also varied. To be as comprehensive as possible whenassessing the evidence to inform the grades for factors inluencing PA,
several benchmarks were considered (Table 2). This process has beenused for the AHKC Report Cards for the past 10 years. The Expert
Group in each country discussed the total evidence base before reaching consensus on the grade assigned for each indicator. To enhance thecomparability of grades among jurisdictions, standardized guidance
was provided by the AHKC Report Card leaders, including participation in most grade assignment processes. Expert Groups consisting ofchildhood PA researchers, practitioners, and leaders from each country
were invited to identify available information and serve as a consensus
committee for assigning grades. Country-speciic details for each Report
Card are summarized in the individual papers in this special issue of thejournal.1,9–22 Despite variation in country data sources and the extent
to which country Expert Groups were able to apply the recommended
benchmarks, it is believed that the grades across all indicators arecomparable and certainly informative of global variation in importantfactors related to PA among children and youth. Internet links to theReport Cards for each country are provided in Table 3.

Global Matrix Results
Table 4 presents the global matrix in rank order by grade. For mostindicators there is a large spread in grades across countries. Countries that are leading in certain indicators are lagging in others. Overall the grades for indicators of PA behavior around the world are low/poor. Many countries have insuficient information to assign a grade,particularly for the Active Play and Family and Peers indicators.
Grades for Sedentary Behavior in general are better in low-income
countries. The Community and Built Environment indicator received
high grades in high-income countries and notably lower grades inlower-income countries. There was a pattern of higher PA and lower
sedentary behavior in countries reporting poorer infrastructure andlower PA and higher sedentary behavior in countries reporting better
infrastructure. Similarly, some countries have relatively high grades
for the policy environment but relatively low grades for the healthbehavior indicators the policies are targeting.

Discussion
Perhaps the most notable inding from the global matrix is thesubstantial variation in the grades assigned to the 9 indicators of
PA. This is encouraging for at least 3 reasons. First, it demonstrates
that at least some countries are succeeding in each of the important
indicators examined in the global matrix. Second, such internationalvariation consolidated in this fashion presents an opportunity forcross-fertilization of ideas for improving the grades. Third, the global
matrix provides a framework for research aimed at understanding thedifferences between and within different nations (eg, urban versus
rural differences). It is also clear from Table 4 that no one country isleading or lagging in all indicators but, rather, each country has its
own blend of successes and challenges at this point in time. Overall
there is much that needs to be done to enhance the PA behaviors andopportunities for children and youth around the world, and tackling
this challenge together may provide unique insights that could not be
achieved in isolation. A discussion of who is leading and lagging ineach indicator is presented below in the context of existing international research. Subsequently, important disparities and inequities,
research and surveillance gaps and needs, recommendations for
improving the grades, and future directions are discussed.

Who is Leading and Lagging?
Overall Physical Activity. New Zealand and Mozambique reported

the highest grades (“B”) for Overall Physical Activity while 10countries reported low or failing grades (“D” or “F”), suggesting
there is widespread evidence of a childhood physical inactivity
crisis. This was consistent with a comprehensive analysis that
included data from 105 countries around the world: only 20% of

Table 1

Grading Framework for the Report Card

GradeInterpretationA

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%)

Global Matrix of Grades

Table 2

S115

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, trafic 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 theirstudents% 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 physicalactivity (eg, gymnasium, outdoor playgrounds, sporting ields, 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) speciically geared toward promoting physical activity% of children or parents with facilities, programs, parks, and playgrounds available to them in theircommunity% 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 communitythat 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 andyouth
Allocated funds and resources for the implementation of physical activity promotion strategies and initiatives for all children and youth
Demonstrated progress through the key stages of public policy making (ie, policy agenda, policy formation, 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
moderate- to vigorous-intensity physical activity (MVPA).24 While
Report Card grades were generally higher in low-middle income
countries (Mozambique, Kenya, Mexico, Nigeria), this relationshipwas not uniform as New Zealand reported a high grade and Ghana
a low grade for Overall Physical Activity.

Signiicant variation in sampling and measurement procedures
among countries limits comparison and understanding of PA behaviors. These limitations have been discussed in detail elsewhere.25–28
Nevertheless, international comparisons can illustrate potentially
important patterns and trends. For example the Mozambique
Report Card manuscript ascribes the inherently high activity level

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Tremblay et al

Table 3

Internet Addresses for Individual Country Report Cards

Jurisdiction

Weblink

Australia

www.activehealthykids.com.au

Canadawww.activehealthykids.ca

Colombia

epiandes.uniandes.edu.co

Englandwww.activehealthykidsengland.co.uk

Finlandwww.jyu.i/sport/ReportCard

Ghana

alwag.org/family/ahk-gh/rc2014

Irelandwww.getirelandactive.ie/get-info/reportcard

Kenya

www.hakkenya.org

Mexicoobesired.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

Scotlandwww.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 andsubsistence chores,17 similar to Kenya;15 however, New Zealand’s
grade seems to be achieved primarily through organized sport participation and active play.18
The more global observation that PA levels of children andyouth in many countries are low is supported by self-reported PA
data for children and youth from 39 countries around the world:
only 23%, 19%, and 15% of 11-, 13-, and 15-year-olds, respectively,
reported at least 60 minutes of daily MVPA.29 Intuitively it seems
that PA levels of children and youth have declined in recent decades.
Some circumstantial evidence supports this intuition including
an examination of anthropological and lifestyle transitions.30–34
Although empirical surveillance evidence to support the temporaldecline in childhood and adolescent PA levels appears lacking, such
evidence may be constrained by measurement issues.28
Temporal changes in physical itness are supportive of a decline
in habitual PA. An analysis of survey data for over 25 million 9to 17-year-olds from 28 countries has demonstrated international
declines in the ability of children and adolescents to perform aerobic
exercise (–4% per decade) since 1975.35,36 Canadian data have also
shown a dramatic decrease in itness levels in one generation.37,38
There is considerable geographical variability in aerobic itness,with children and adolescents from Northern Europe performing
the best (mean percentile ± 95% CI: 72 ± 0.4%), followed by African children (55 ± 2.0%), those from the Paciic Rim (50 ± 1.6%),
Central/Western Europe (50 ± 0.4%), Southern Europe (36 ± 3.2%),
and South America (30 ± 0.4%).39 Because of this geographicalvariability, the global declines are much more important in children
and youth from countries that have poorer baseline aerobic itness.
A recent systematic review examining temporal trends in PA anditness among children and youth in sub-Saharan Africa foundinsuficient evidence to determine any clear changes over time.40
The review did ind adverse associations between PA, sedentary
behaviors, and itness, and urban living and higher socioeconomic
status, suggesting that traditional economic development may
paradoxically be related to reduced healthy active lifestyles anditness.40

Organized Sport Participation. Most countries had suficientevidence to grade the Organized Sport Participation indicator.
New Zealand and Australia reported the highest grades, withapproximately two-thirds of children in these countries participatingin organized sport.9,18 Most countries clustered around a “C” grade,indicating that about one-half of children and youth participated in
sport. Evidence from Australia41–43 and the United States44 suggested
that these relatively high grades were set to continue given recent
increases (+5% points per decade) in the prevalence of children
who regularly participated in organized sport. The Mozambique
Report Card (“F”) suggested that the opportunity and availabilityof organized sport were limited, though data were lacking.
Evaluation of grades for Organized Sport Participation, on one
hand, and School and Community and the Built Environment, on theother, suggested a relationship among these indicators. Countries
with relatively good grades for Organized Sport Participation also
reported relatively good grades for School and Community andthe Built Environment (eg, Australia, Canada, Finland), whereas
countries with low grades for Organized Sport Participation reported
low grades for School and Community and the Built Environment(eg, Colombia, Mexico, Mozambique). This makes sense sinceorganized sport and PA opportunities require space, facilities,
equipment, and supervision. While most countries had some dataon sport participation, details of the quality, frequency, duration,
intensity, context (eg, physical education, extracurricular, community sport), and seasonality of participation varied signiicantly
and/or were generally lacking.
Active Play. The 2012 AHKC Report Card asked the question“Is active play extinct”?5,45 It cited evidence showing low levels ofactive play (deined here as freely chosen, spontaneous and selfdirected physical activity involving an element of fun46,47) in Canada
and evidence of downward trends.5,45 Active play has historicallyoccurred outdoors but with the allure of electronic screens, children
and youth are increasingly spending their time indoors and usuallysedentary (see Sedentary Behavior indicator below). Although
Canadians value outdoor time, they strongly agree that children do
not spend enough time outdoors.48 Only 5 countries felt they had

S117

FinlandGhana

Sedentary
Behaviors

Australia

Family &Peers

Australia

D-

United States

Ireland

CanadaAustralia

Ireland

CanadaAustralia

South Africa

Ghana

Finland
Ghana

MexicoColombiaD

New ZealandFinland

Colombia

EnglandUnited States

IrelandEnglandNigeria

England

Scotland

D+

C-

Kenya
Mozambique

South Africa

Finland
Ghana

Kenya

NigeriaC

South Africa

CanadaMexicoC+

Australia

United States

MexicoFinland

Colombia

Ireland

New ZealandAustralia

Scotland

New Zealand

Kenya

Finland

CanadaSouth Africa

MexicoGhana

United States

IrelandMozambique

Kenya

CanadaNew ZealandSouth Africa

Ghana

New ZealandUnited States

Scotland

MexicoNigeria

Finland
Ireland

Kenya

Mozambique

Kenya

Kenya

Australia

B-

New ZealandFinlandEngland

SchoolCommunity &Built Environment

England

New Zealand

Active Play

ActiveTransportationB

New ZealandOrganized
Sport
Participation

CanadaMozambique

Overall Physical
Activity

Global Matrix Presented in Rank Order by Grade

B+

A-

A

A+

Grade

Table 4Ghana(continued)

Mozambique

MexicoKenya

CanadaAustralia

South Africa

ScotlandFinland

Colombia

Government
Strategies &Investments

S118

F

MexicoMozambique
NigeriaSouth Africa
United States

Ghana
Ireland
MexicoScotlandSouth Africa
United States

IrelandEngland

Colombia

Family &
Peers

Ghana

Mozambique

England

South Africa

ScotlandNigeria

CanadaSedentary
Behaviors

England

Colombia

United States

ActiveTransportation

Colombia

Australia
CanadaNigeria

Active Play

ScotlandMozambique

Organized
Sport
Participation

Nigeria

Colombia

SchoolNigeria

Kenya

Colombia

Mexico MozambiqueCommunity &Built Environment

Nigeria

United States

New ZealandIrelandEnglandGovernment
Strategies &Investments

Note. The grade for each indicator is based on the percentage of children and youth meeting a deined 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.

INC

ScotlandGrade(continued)

Overall Physical
Activity

Table 4

Global Matrix of Grades

enough data to grade this indicator. Grades ranged from “B” in New
Zealand to “D” in Finland. Data from New Zealand indicated thatapproximately three-quarters of children reported participating in
active play,49 spending on average 78 minutes per day in free play.50
In contrast, the Finland Adolescent Health and Lifestyle Survey51
found only one-third of 12- to 18-year-olds participated in physicalactivities outside school or sports clubs at least 4 times per week.52 Tencountries graded this indicator as “incomplete” because of insuficient
data and/or lack of clarity on the benchmark or the deinition of active
play. Canada has struggled with grading this indicator across its 10
years of producing Report Cards for similar reasons.3
It is commonly believed in developed countries that active,
unstructured (free) play is decreasing for a variety of reasons,
including increased screen time, safety concerns (eg, trafic, stranger
danger), emphasis on organized youth sports, and parental work
schedules. The same concern is emerging in developing countries,
especially in urban and peri-urban areas.31,32 If active play was
MVPA it should be captured in the Overall Physical Activity grade.
However, most active play is likely light-intensity PA, and theimportance of light/incidental PA, especially in the form of active
play, is largely unknown and likely varies signiicantly among
countries and in urban and rural areas in lesser developed countries.
Furthermore, incidental active play may be sporadic and dificult
to quantify or recall through self-report, and impossible to discernwith pedometers or accelerometers. Interestingly, children aged
7–12 years from 25 countries were interviewed about their favorite
pastime and “playing with friends” was the top response (30%); it
was more popular among children in Scandinavian countries andJapan (≥ 40%).53 Data from the United States between 1981–2003
showed that for children aged 6–12 years “playing” was the mostcommon pastime after television viewing.34
Active Transportation. All countries except Colombia graded

the Active Transportation indicator, with grades ranging from “B”
in Finland, Kenya, Nigeria, and Mozambique to “F” in the UnitedStates. Active transportation may be a necessity for some children incountries such as Nigeria,19 Kenya,15 and Mozambique,17 whereas it
may be more a cultural norm in Finland. In Finland, approximately
75% of children and youth actively commuted to school when the
distance ≤ 3 km.54 In contrast, in the United States < 15% of children
and youth used active transportation to get to and from school.22
The most robust data available in most countries related speciicallyto active school transportation.55,56 The percentage of children andyouth in Canada, the United States, the United Kingdom, Australia,
and New Zealand who cycled to/from school was generally low,
whereas the prevalence of cycling or walking to/from school incountries from continental Europe and in China was relatively highcompared with what is seen in North America, the United Kingdom,and Australasia.57
Studies from North America typically report lower levels ofactive school transport in secondary school students than in primaryschool students.58–62 This age-related or school transition-related
decline may not be universal and may not always follow the agerelated decline generally seen in overall PA. For example, Ireland
did not observe such declines in active transportation.14
Even though active transportation has been associated withincreased PA and itness63 evidence suggests that levels of active
transportation are declining.64,65 There have been consistent declines
in children’s use of active transportation in recent decades, withdeclines in the prevalence of cycling or walking to/from school
observed in Australia (–7 percentage points per decade, 1971–2004),42,66,67 Brazil (–16 percentage points per decade, 2002–07),68
Canada (–8 percentage points per decade, 1986–96),69 Switzerland

S119(–7 percentage points per decade, 1994–2005),70 the United Kingdom (–6 percentage points per decade, 1975–2012),71–73 and theUnited States (–8 percentage points per decade, 1969–2009).74,75
Parents in Canada76 and Kenya32 have reported that their children
do not use active transportation as frequently as they (parents)
did as children. Circumstantial evidence of a temporal decline inactive transportation other than to/from school can also be gleaned
from evidence of a restriction of independent mobility afforded tochildren,77 which would limit their active travel opportunities. For
example, temporal trends in socially or culturally acceptable roaming distances where children are allowed to wander freely almost
certainly vary substantially across and within countries although thisis poorly understood. Furthermore, active transportation, whether forschool, work, chores, or play varies dramatically between urban andrural settings, particularly in developing countries where automobiletransport is often not available.30–32 It will be important to carefully
monitor active transportation behaviors in rural areas in developing
countries as they transition to motorized transport and subsistence
demands become increasingly mechanized.
Sedentary Behavior. As with other indicators there is signiicant
global variation in sedentary behaviors although the majority
of countries have very poor or failing grades. Ghana and Kenya
reported the best grades on this indicator; well over half of children
and youth reported spending no more than 2 hours per day on screen
time. Intuitively it seems that less access to sedentary behavior
promoting devices (eg, motorized vehicles, electronic screens)would be associated with less sedentary behavior. Indeed, recent
research comparing 17 high-, middle-, and low-income countries
demonstrated that ownership of household devices, including
televisions, computers, and cars, increased as country income level
increased, and that ownership was positively associated with obesityand diabetes in low- and middle-income countries.64 Of particular
relevance to the present discussion, this relationship was partiallymediated by decreased PA and increased sedentary behavior.78
As the world becomes increasingly “wired,” auto-dependent andurbanized, the temptation and convenience of sedentary living
seems likely to increase. Self-report sedentary behavior data on
representative samples of children and youth from 39 countries
around the world revealed that 56%, 65%, and 63% of 11-, 13-, and15-year-olds, respectively, watched 2 or more hours of television
per day on weekdays.29 In a study of parents from 25 countries
around the world, 44% of parents agreed that their children spent
too much time watching television or playing electronic games.53
The overall indings from the global matrix and international
surveys suggest that when sedentary behaviors are high, PA levels
are low. As a result, there is growing recognition of the importanceof reducing sedentary behavior in children in addition to promoting
PA.79,80 Canada has recently developed speciic Sedentary Behaviour Guidelines81,82 that are separate and distinct from existing PA
guidelines. The United Kingdom83 and Australia84–86 have also
recently made speciic recommendations about limiting sedentary
time to promote healthy growth and development of children. Suchguidelines or recommendations are not common yet in developing
countries and it seems public health messaging around limiting
screen time in particular may be important as lifestyle transitions
occur throughout the world. It is important to note that screen time
consists of much more than traditional television viewing whichshould be relected in future surveillance. While the sedentary
behavior indicator was informed in all countries exclusively by
screen-time, or speciically television viewing time, nonscreen
sedentary behaviors, and their relationship with health outcomes
are important to understand and require further research.

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Tremblay et al

Family and Peers. While the importance of family and peer

support for the promotion of PA is universally recognized andsubstantiated by recent reviews,87–90 this indicator is very dificult
to grade based on a lack of empirical data adhering to the grading
framework (Table 1). This dificulty was apparent in the reportcard grades summarized in this overview: 9 countries assigned
an “incomplete” grade due to lack of data. The countries that did
assign grades were tightly clustered around a “C” grade, with lessvariability than for any other indicator. As can be seen from Table
2, a variety of benchmarks were used to inform this indicator, withthe availability of data to grade against each benchmark varying
among countries.1,9,12,15,18,20 A survey of parents in 25 countries withchildren birth to 12 years of age in 2010 noted an average of 14.3
hours per week spent with their children in all types of play during
a typical week; means ranged from 10.5 hours in Denmark to 20.0
hours in China.53 Note, however, that family size and composition,
employment logistics, urban-rural residence, climate, and variable
deinitions of “play” may confound the results and interpretations.
Hence, given the available data, it is dificult to draw any irm
conclusions from these indings.
School. Grades for the School indicator ranged from “A-” inEngland to “F” in Colombia with a relatively even distribution ofgrades by other countries between these extremes. The top 5 grades
were from high-income countries while the bottom 4 grades werefrom middle- to low-income countries. The high grade for England
represented favorable composite evidence on school physicaleducation (PE) delivery, school policies and investments in PA, andschool facilities and availability.11 The low grade in Colombia wasbased on the observation that only 6.1% of school-aged children
received PE classes from a professional instructor.91 Of interest,
grades for the Overall Physical Activity indicator did not appear
to be closely related to school-based opportunities for PE or PA.
International comparisons of PE and school-based delivery of
PA are scarce. A recent comparison of 30 European countries aroundinitiatives and strategies to promote PE and PA in schools, timespent on PE, curriculum details, PE assessment, teacher education,and extracurricular sports highlighted important differences acrossEurope,92 and noted that PE in some European countries was now <10% of total curricular time.92 Elsewhere, it has been reported thatthe quality and/or quantity of PE has recently diminished in many
countries in recent years, with losses of 15%–20% of weekly time
allocation due to cost-reduction or time allocation for other school
subjects,69,93,94 though areas of Australia have actually shown small
increases.42,66 Moreover, there is a discrepancy between curricularschedules and actual practice in many countries,93 an issue raised in
the Kenya and Ireland report cards.14,15 Unsatisfactory infrastructure,lack of equipment and inancial resources, lack of training of PE
teachers, a gap between policy and practice, curricular demands
that exceed teacher competence, and over-sized classes are otherconcerns raised by PE leaders from around the world.93
Community and the Built Environment. This indicator received
the highest grades, on average, with 7 countries assigning gradesof ≥ “B-.” While the grades were generally high, they ranged from
“A-” in Australia to “F” in Mexico and Mozambique. A general
pattern of higher grades in higher-income countries and lower
grades in lower-income countries was evident, which makes intuitive
sense. Although there is much emphasis on improving the built
environment, it is already reported as quite good in many countries.
Canadians quite reliably reported rather good PA infrastructure,
availability, and programming.3 Despite consistent high grades
for the Community and Built Environment indicator in Canada,

the actual reported use of parks, playgrounds, and programs wasquite low.95 It appears that perceptions of quality and safety of
local facilities and infrastructure did not necessarily translate into
PA. On a more global scale, this same relationship appeared toemerge with countries that reported rather good PA environmentsin the community generally showing poor Overall Physical Activity
grades, while countries with lower grades on Community and Built
Environment generally showing higher Overall Physical Activity
grades.
Other results from several countries have also challenged
conventional thinking about the relationship between PA and characteristics of the built environment.96 Using latent class analysis of
built environment features reported by adults from 11 countries, 5neighborhood patterns emerged across countries; 2 were speciically associated with meeting PA guidelines: irst, an overall activity
supportive environment (eg, many shops and transit stops withinwalking distance, sidewalks on most streets, low cost recreation
facilities near-by), and second, highly walkable yet unsafe environments with few recreation amenities.96 Although this study wasadult-centric, the results add evidence that relationships between
the environment and PA are complex and probably speciic to geographic area, culture, and/or country.96
While there is universal support for the promotion of PA
enhancing environments, evidence suggests a need to challenge howsuch environments should be deined. In some cases, it may be that“less is more” for the promotion of exploratory play and incidental
PA for some children. Nevertheless, international comparisons asevident in the global matrix and other surveys96 are invaluable inassessing the universality of interventions and approaches, whileemphasizing the need to use cross-cultural research in the searchfor solutions to the childhood inactivity crisis.
Government Strategies and Investments. The Government
Strategies and Investments indicator was dificult to grade. Assigned
grades relied more on expert consensus than the grading framework(Table 1). Nevertheless, 10 countries felt conident assigning a
grade. Grades were tightly bunched in the “B” and “C” range
indicating an overall favorable assessment, regardless of the income
or development status of the country. The individual country reportcards discussed a variety of policies, strategies, and investments
related to different indicators and collectively represent a catalog
of ideas for governments to consider.1,9–22
Many countries had relatively high grades for the policy
environment both in schools and in governments, but relatively
low grades for the indicators of health behaviors that the policies
were targeting. Whether this relects ineffective policies, lack ofimplementation or the reactive nature of policy development isunclear. The fact that more developed countries had more developed
policy environments than less developed countries, but generally
had lower levels of desired behaviors indicates a major mismatch(ie, policies and strategies may have been reactive to problems after
they had emerged rather than preventive). Further, the implementation of reparative policies may be suboptimal (eg, ineffective,
unsustainable, insuficiently scaled). Given the experience fromdeveloped countries, it may be opportune to rally support for the
implementation of proactive campaigns, strategies, and investments
in developing countries in an effort to preserve inherent healthy
active living behaviors.
Other Indicators. While not discussed in the context of the global

matrix it is worth noting that most countries added additional
indicators to their Report Cards; indicators of particular relevanceor importance to their jurisdiction. Examples of additional indicators

Global Matrix of Grades

included body weight status (overweight and/or obesity, in somecases in the presence of persistence underweight), nutrition/
healthy eating indicators, physical fitness, motor skills, andnongovernmental strategies and investments. Details are reported
in individual country Report Cards.1,9–22

Disparities and Inequities
Variability in the grades comprising the global matrix demonstrates
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 ield,” provides rich, comparative informationthat can assist jurisdictions and challenge conventional wisdom. For
example, should higher-income countries be encouraged to relax
efforts to construct environments for children to play (thereby lowering their grades), or should low-income countries be encouraged toinvest in constructing environments shown to promote PA in otherjurisdictions (thereby improving their grades)?
It is worth highlighting that very little information on the accessibility and opportunity for PA among children and youth with adisability (physical, mental, sensory) was reported in the country
Report Cards. This group with special needs not only represents asigniicant proportion of children and youth globally,97,98 it is among
the most vulnerable to physical inactivity and also the group thatmight gain the greatest beneit from a “level playing ield.” Theprevalence of children and youth with disabilities varies substantially among countries and disability category.98 Understanding
and learning from international variability in efforts to address
disparities and inequities among this marginalized population could
increase awareness and provoke required changes. This is an area
where more research and surveillance is required.
Disparities and inequities exist within countries, but the extent
varies among countries.1,9–22 The most notable within-country

S121

disparity or inequity gradient related to the Organized Sport Participation indicator. Because participation in organized sport often
requires resources (registration fees, equipment, travel), it is more
susceptible to socioeconomic or geographic (urban-rural) gradients.
Such gradients were noted in several Report Cards. Most countries
also reported a gender bias favoring boys in organized sport participation. International and cultural variation in gender roles andexpectations complicate the transferability of interventions to help
level the playing ield between genders.

Research and Surveillance Gaps and Needs• While this global matrix with 15 nations is a major advance,
there are a number of “geographical gaps,” notably the lackof representation from Asia, the Eastern Mediterranean, andArab countries, much of Eastern and Western Europe, SouthAmerica, Paciic Islands, and the Caribbean (see Figure 1). It is
hoped that the creation of the irst global matrix will encouragenations from these under-represented areas to develop Report
Cards in the future and further our understanding of global
variation while assisting with solution cross-fertilization.
Efforts are currently underway in at least 4 additional countries(Hong Kong, Japan, Malaysia, Wales).
• There is a need for more research on the correlates and determinants of PA and sedentary behaviors in children and youth
in different countries. Determinants likely vary by region andacross cultures. This information is essential to the identiication of future Report Card indicators and novel intervention
possibilities.
• There is a need for robust, standardized measures of PA andsedentary behaviors on children and youth from countries
around the world.

Figure 1 — Global map indicating location of countries participating in the global matrix.

S122

Tremblay et al• There is a need for healthy movement behavior information
on young children (toddlers and preschoolers, aged 1–5 years)
from countries around the world to understand best practices
for the promotion of healthy growth and developmental trajectories.
• More research and surveillance are required to assess thelevels and importance of active, unstructured play and/or lightintensity PA and understand their relationship with holistic
health outcomes.
• Enhanced efforts are required to collect public health surveillance data for those indicators that could not be graded (graded
incomplete); to improve the measurement of existing indicators with better, standardized measures and more representative samples; to extend measures to include emerging healthbehaviors which have not been measured in surveillance in thepast (eg, sitting time, breaks in sitting time, nonscreen timesedentary behaviors, light PA); and to include marginalizedgroups.
Though not speciic to the global matrix a recent Delphi
survey of international experts established a ranked set of international research priorities in child and adolescent PA and sedentary
behavior.99 The top 3 priorities were: development of effective andsustainable interventions to increase long-term PA among children
and youth; assessment of policy and/or environmental changes
and their inluence on PA and sedentary behaviors of children andyouth; and implementation of prospective, longitudinal studies to
examine the independent effects of PA and sedentary behaviors on
health from birth to middle age.99

Recommendations for Improving the Grades andFuture Directions• Expand our work as a global community of childhood PA
researchers and advocates to learn from one another and challenge conventional within country solutions with internationalcross-fertilization of ideas and approaches. This may be facilitated by the creation of a global federation or network of active
healthy kids organizations or research or advocacy groups.
• International efforts are needed to establish a core list of indicators, with clear deinitions and documented benchmarks, toserve future global matrix efforts.
• Developing countries should take advantage of PA and sedentary behavior guideline work already done in many high-income
countries, and build on this foundation to create and promoteculturally relevant guidelines for the respective countries. This
would serve to promote healthy living awareness and messaging
while assisting with future surveillance.
• Countries should use the between-nation variation in grades
revealed by the global matrix to stimulate greater policy efforts
aimed at improving the grades.
• Conduct regular capacity building courses to support healthy
active living research in various jurisdictions.
• There is a need to gather and promote promising practices andprograms from low- and middle-income settings and marginalized communities in high-income settings that have managed
to overcome the problems of crime and safety, environmental
justice, resource limitations, and competing agendas. If such
examples cannot be found, then there is a need for funders,sponsors, and donors to create a call for such demonstration
projects, with suficient funding to build in rigorous evaluation.

• International, cross-cultural efforts should be used to inform
creative solutions and interventions to inluence the habitual
movement behaviors of children around the world, recognizing
the variation in social norms and environmental realities while
respecting the biologically rooted and curiosity-driven desires
and impulses of children and youth. Countries should takeadvantage of policy work/documents that have been developedin other countries (eg, PA strategies, active play plans, cycle
frameworks). An inventory and library of existing documentsin each country should be created for reference purposes.
• Volunteerism can be an important nongovernmental, community-based support for sport and PA. While delivery of sport andPA opportunities should not be reliant on volunteers, models
of practice worldwide on how to involve and retain volunteers
or lay leaders would be useful.

Conclusion
The global matrix provides new information upon which researchers, advocates, practitioners, and policy-makers can relect andderive inspiration for future work. International cooperation andcross-fertilization is encouraged to conquer existing challenges,
understand underlying mechanisms, derive innovative solutions
and overcome the expanding childhood physical inactivity crisis.
Acknowledgments
The authors would like to thank Active Healthy Kids Canada, especially
Jennifer Cowie Bonne and Lindsay Whiting, for their leadership in planningand hosting the Global Summit on the Physical Activity of Children. The
authors are indebted to the individual country Report Card Project Managers and/or Scientiic Oficers including: Dr. Natasha Schranz (Australia),
Joel Barnes (Canada), Dr. Silvia Gonzalez (Colombia), Hannah Wilkie(England), Dr. Catherine Woods (Ireland), Stella Muthuri and Joy Wachira(Kenya), Karla Galaviz (Mexico), Adewale Oyeyemi (Nigeria), Dr. Smita
Dick and Prof. Geraldine McNeill (Scotland), Monika Uys (South Africa),and Kara Dentro (United States).

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