Journal of Physical Activity and Health, 2018, 15(Suppl 2), S298-S314
https://doi.org/10.1123/jpah.2018-0431© 2018 Human Kinetics, Inc.

ORIGINAL RESEARCH

Report Card Grades on the Physical Activity of Children and YouthComparing 30 Very High Human Development Index Countries
Salomé Aubert, Joel D. Barnes, Nicolas Aguilar-Farias, Greet Cardon, Chen-Kang Chang,
Christine Delisle Nyström, Yolanda Demetriou, Lowri Edwards, Arunas Emeljanovas, Aleš Gába,
Wendy Y. Huang, Izzeldin A.E. Ibrahim, Jaak Jürimäe, Peter T. Katzmarzyk, Agata Korcz,
Yeon Soo Kim, Eun-Young Lee, Marie Löf, Tom Loney, Shawnda A. Morrison, Jorge Mota,
John J. Reilly, Blanca Roman-Viñas, Natasha Schranz, John Scriven, Jan Seghers,
Thomas Skovgaard, Melody Smith, Martyn Standage, Gregor Starc, Gareth Stratton, Tim Takken,
Tuija Tammelin, Chiaki Tanaka, David Thivel, Richard Tyler, Alun Williams, Stephen H.S. Wong,
Paweł Zembura, and Mark S. Tremblay
Background: To better understand the childhood physical inactivity crisis, Report Cards on physical activity of children andyouth were prepared concurrently in 30 very high Human Development Index countries. The aim of this article was to present,
describe, and compare the ﬁndings from these Report Cards. Methods: The Report Cards were developed using a harmonizedprocess for data gathering, assessing, and assigning grades to 10 common physical activity indicators. Descriptive statistics were
calculated after converting letter grades to interval variables, and correlational analyses between the 10 common indicators were
performed using Spearman’s rank correlation coefﬁcients. Results: A matrix of 300 grades was obtained with substantial
variations within and between countries. Low grades were observed for behavioral indicators, and higher grades were observed
for sources of inﬂuence indicators, indicating a disconnect between supports and desired behaviors. Conclusion: This analysis
summarizes the level and context of the physical activity of children and youth among very high Human Development Index
countries, and provides additional evidence that the situation regarding physical activity in children and youth is very concerning.
Unless a major shift to a more active lifestyle happens soon, a high rate of noncommunicable diseases can be anticipated when
this generation of children reaches adulthood.
Keywords: children physical activity, sedentary behavior, international comparison, Global Matrix

Aubert, Barnes, and Tremblay are with Healthy Active Living and Obesity Research Group, CHEO Research Institute, Ottawa, Ontario, Canada. Aguilar-Farias is with the
Department of Physical Education, Sports and Recreation, Universidad de La Frontera, Temuco, Chile; and UFRO Actívate Research Group, Universidad de La Frontera,
Temuco, Chile. Cardon is with the Department of Movement and Sports Sciences, Ghent University, Ghent, Belgium. Chang is with the Department of Sport Performance,
National Taiwan University of Sport, Taichung, Taiwan. Delisle Nyström is with the Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, Sweden.
Demetriou is with the Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany. Edwards, Stratton, and Tyler are with Applied Sport
Technology Exercise and Medicine Research Centre, Swansea University, Swansea, United Kingdom. Emeljanovas is with Lithuanian Sports University, Kaunas, Lithuania.
Gába is with the Faculty of Physical Culture, Palacký University Olomouc, Olomouc, Czech Republic. Huang is with the Department of Sport and Physical Education, Hong
Kong Baptist University, Hong Kong, China. Ibrahim is with Aspetar Orthopedic and Sports Medicine Hospital, Doha, Qatar. Jürimäe is with the Faculty of Medicine,
Institute of Sport Sciences and Physiotherapy, University of Tartu, Tartu, Estonia. Katzmarzyk is with Pennington Biomedical Research Center, Baton Rouge, LA, USA.
Korcz is with the Department of Didactics of Physical Activity, Poznań University of Physical Education, Poznań, Poland. Kim is with the Department of Physical Education,
Seoul National University, Seoul, South Korea; and the Seoul National University Institute of Sports Science, Seoul, Republic of Korea. Lee is with the School of Kinesiology
and Health Studies, Queen’s University, Kingston, Ontario, Canada. Löf is with Group MLÖ, Department of Biosciences and Nutrition, Karolinska Institutet, Solna, Sweden;
and the Department of Medicine and Health Sciences, Linköping University, Linköping, Sweden. Loney is with the College of Medicine, Mohammed Bin Rashid Universityof Medicine and Health Sciences, Dubai, United Arab Emirates. Morrison is with the Faculty of Health Sciences, University of Primorska, Izola, Slovenia. Mota is with theCentro de Investigação em Atividade Física Saúde e Lazer (CIAFEL-FADEUP), University of Porto, Porto, Portugal. Reilly is with the Physical Activity for Health Group,
University of Strathclyde, Glasgow, Scotland. Roman-Viñas is with Nutrition Research Foundation, Barcelona, Spain; the School of Health and Sport Sciences (EUSES),
Universitat de Girona, Salt, Spain; and the CIBER Physiopathology of Obesity and Nutrition (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain. Schranz is with theAlliance for Research in Exercise, Nutrition and Activity, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia. Scriven is with
Jersey Sport Foundation, Jersey, United Kingdom. Seghers is with the Department of Movement Sciences, KU Leuven, Leuven, Belgium. Skovgaard is with the Research andInnovation Centre for Human Movement and Learning, University of Southern Denmark, Odense, Denmark; and the Research Unit for Active Living, Department of Sports
Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark. Smith is with the School of Nursing, The University of Auckland, Auckland, New
Zealand. Standage is with the Department for Health, Centre for Motivation and Health Behaviour Change, University of Bath, Bath, United Kingdom. Starc is with theFaculty of Sport, University of Ljubljana, Ljubljana, Slovenia. Takken is with Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.
Tammelin is with the LIKES Research Centre for Physical Activity and Health, Jyväskylä, Finland. Tanaka is with the Division of Integrated Sciences, J. F. Oberlin
University, Machida, Japan. Thivel is with the Laboratory of Metabolic Adaptations to Exercise Under Physiological and Pathological Conditions (AME2P), Research Centerfor Human Nutrition (CRNH Auvergne), Clermont Auvergne University, Clermont-Ferrand, France. Williams is with Guernsey Education Services, St. Peter Port, Guernsey.
Wong is with the Department of Sport and Physical Education, The Chinese University of Hong Kong, Hong Kong, China. Zembura is with Social Challenges Unit, The
Robert B. Zajonc Institute of Social Science, University of Warsaw, Warsaw, Poland. Tremblay (mtremblay@cheo.on.ca) is corresponding author.

S298

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

Very High HDI Country Physical Activity Grades for Children and Youth

A compelling body of empirical work shows moderate to highlevels of physical activity to be associated with a lower risk ofcardiovascular disease and all-cause mortality among adults.1 Conversely, physical inactivity has been recognized by some as “thebiggest public health problem of the 21st century.”2,3 Among schoolaged children and adolescents, meeting physical activity guidelines
is associated with positive physical, psychological, social, andcognitive health indicators,4,5 while physical inactivity, deﬁned as
not meeting physical activity guidelines, is associated with adverse
physical, mental, social, and cognitive health outcomes.4–7
The Human Development Index (HDI) is a composite index,
ranging from 0 to 1, calculated using education, life expectancy,and per capita income.8 This index was created by the United
Nations Development Programme to rank countries on a scale ofhuman development conceptualized in terms of capabilities ofhumans within the countries to function.9 To be classiﬁed asvery high HDI, the score of a country must be equal or superior
to 0.80. Among children living in countries categorized as being
very high by the HDI, moderate- to vigorous-intensity physicalactivity (MVPA) was positively related to markers of cardiovascular health10–13 and self-reported health-related quality of life.14
Physical inactivity has been estimated to be responsible for at least
10% and 9% of all-cause mortality in North American and inEuropean countries, respectively.15 Furthermore, very high-income
countries bear the largest proportion of economic burden ofphysical inactivity worldwide (81% of health care costs and
60% of indirect costs).16 However, the majority of children17–21
and youth19–25 do not meet the current recommendations of
60 minutes of MVPA per day26 in very high HDI European andNorth American countries and regions. Similar ﬁndings wereobserved among children and/or adolescents from other very
high HDI countries or regions such as Australia,6 Chile,27 Chinese
Taipei (Taiwan),28 Hong Kong,29 Japan,30 South Korea,31 Qatar,32
and the United Arab Emirates.32–34 Very high HDI countries sharesimilar characteristics in terms of education, life expectancy, andincome; however, differences also exist geographically, politically,
culturally, religiously, and environmentally that may inﬂuencephysical activity behavior differently across the very high HDI
countries. Cooper et al35 found that there was substantial
between-country variation in objectively measured MVPAin the International Children’s Accelerometry Database, evenbetween apparently similar countries, and concluded that further
research is needed to explore environmental and sociocultural
explanations for these differences.
To develop a better understanding of childhood physicalactivity and inactivity across countries, the ﬁrst Global Matrix(Global Matrix 1.0) of Report Card grades on physical activity waslaunched in 2014.36 Report Cards, based on the Canadian Report
Card model,37 were developed by research teams from 15 countries(including 8 very high HDI countries) using a harmonized process
for data gathering, assessing, and assigning grades.36 For eachparticipating country, grades were assigned to 9 common physicalactivity indicators: Overall Physical Activity, Organized Sport
Participation, Active Play, Active Transportation, Sedentary Behaviors, Family and Peers, School, Community and Environment,
and Government Strategies and Investments. Global Matrix 1.0
grades provided new information upon which researchers, advocates, practitioners, and policy-makers could reﬂect and deriveinspiration for children’s physical activity research projects andpromotion activities around the world.36
Building on the Global Matrix 1.0, investigators from eachparticipating country committed to repeat and further develop the

S299

Global Matrix initiative along with teams of researchers from 23
new countries. The Global Matrix 2.0, which was released in 2016
in Bangkok, presented a comprehensive summary of the physicalactivity behaviors and sources of inﬂuence indicators from 38
countries (including 24 very high HDI countries).38 Findings
suggested the presence of a complex variety of strengths andlimitations across the participating countries, with some universal
patterns emerging when comparing countries by continent, HDI, or
income inequality. For example, a strong positive correlation
was found between the source of inﬂuence grades (combining
the grades from Family and Peers, School, Community andEnvironment, and Government Strategies and Investments)and HDI.38
In 2017, the Active Healthy Kids Global Alliance39 (AHKGA)
called for more countries to participate in the Global Matrix 3.0.
Forty-nine countries registered and followed the harmonized steps
to develop their country’s Report Card. Out of the 49 participating
countries, 30 (61%) were very high HDI countries, from 5 different
continents: Asia (n = 6), Europe (n = 19), North America (n = 2),
Oceania (n = 2), and South America (n = 1). The aim of this article
is to present, describe, and compare the Report Card grades fromthe very high HDI countries and regions participating in the Global
Matrix 3.0: Australia, Belgium (Flanders), Canada, Chile, Taiwan,
Czech Republic, Denmark, England, Estonia, Finland, France,
Germany, Guernsey, Hong Kong, Japan, Jersey, Lithuania, The
Netherlands, New Zealand, Poland, Portugal, Qatar, Scotland,
Slovenia, South Korea, Spain, Sweden, the United Arab Emirates,
the United States, and Wales. Companion papers published in thisissue of the Journal of Physical Activity and Health present thecollective results from the low and medium HDI countries, and thehigh HDI countries.

Methods
The AHKGA distributed an open call through established networks
for interested countries and opened registration for the Global
Matrix 3.0 in April 2017. As a result, 49 countries from 5 different
continents fully participated in the Global Matrix 3.0. Workgroups
consisting of experts and stakeholders were established in eachcountry to gather the highest quality and most recently publishedand unpublished evidence. The workgroups critically appraised
the available evidence and reported on 10 common indicators(Overall Physical Activity, Organized Sport and Physical Activity,
Active Play, Active Transportation, Sedentary Behaviors, PhysicalFitness, Family and Peers, School, Community and Environment,
and Government) for school-aged children and youth (∼5–17 yold). Through a harmonized and transparent Report Card development process, each country’s workgroup compiled the available
evidence from local, national, or international studies, national
surveys, and ofﬁcial reports, and then synthesized ﬁndings andreached consensus for the grading of each indicator. Full details of
the Report Card development process based on the Canadian
Report Card model37 have been previously described and thedetailed methods for the Global Matrix 3.0 are described in acompanion paper published in this issue of the Journal of Physical
Activity and Health.40
For each of the 49 registered countries, up to 3 joint Report
Card leaders were charged with forming a multidisciplinary
research workgroup (including physical activity experts, stakeholder groups, and communication specialists) to manage theReport Card project, and to ensure the effective communication
between AHKGA and the Report Card team. The workgroups

JPAH 15 Supplement 2, 2018

S300

Aubert et al

identiﬁed and ﬁnalized the list of indicators to be graded (ie, the 10
common indicators and potential additional ones that would be
included in their national Report Card but not in the Global Matrix3.0), and compiled potentially relevant data sets and documentsthat would be used to inform the grades. Countries were advised toconsider and synthesize the best available evidence from approximately the past 5 years for each indicator. Common benchmarks,presented in Table 1, and a common grading scheme, shown in
Table 2, were provided by the AHKGA to the 49 Report Card
workgroups. Experts in each country evaluated the compiled
evidence and reached consensus on the grade assigned for eachindicator. Draft country Report Card grades were submitted alongwith their rationale and were audited by the members of theAHKGA Executive Committee to ensure that the grades wereconsistent with the harmonized benchmarks and grading scheme.
The Report Card leaders were also asked to report details

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

Table 1concerning the data sets used to inform their overall physicalactivity grade (ie, subjective or objective measures, representativeness, instrument used, age range, and sample size).
For analysis purposes, the 49 participating countries andregions were divided into 3 categories using the United Nations’
HDI groupings (low or medium, high, and very high). The results
and analyses presented in this article are on the 30 very high HDI
participating countries.
Descriptive statistics (average grade and SD) were calculated
after converting categorical variables (letter grades) to intervalvariables (see corresponding numbers in Table 2), and the incomplete grades (INC) converted into “No Grade” which was treated asa missing value. Averages were calculated from the interval values
and the ﬂoor (for a given value, the greatest integer less than orequal to the average value) was converted back to a letter grade.
Three scores were computed for analysis: (1) overall score,

Global Matrix 3.0 Indicators and Benchmarks Used to Guide the Grade Assignment Process

Indicator

Benchmark

Overall Physical
Activity% of children and youth who meet the Global Recommendations on Physical Activity for Health, which recommend thatchildren and youth accumulate at least 60 minutes of moderate- to vigorous-intensity physical activity per day on average.
Or % of children and youth meeting the guidelines on at least 4 days a week (when an average cannot be estimated).
% of children and youth who participate in organized sport and/or physical activity programs.

Organized Sport andPhysical Activity
Active Play
Active Transportation
Sedentary Behaviors

Physical Fitness
Family and Peers

SchoolCommunity andEnvironment

Government% of children and youth who engage in unstructured/unorganized active play at any intensity for more than 2 hours a day. % ofchildren and youth who report being outdoors for more than 2 hours a day.
% of children and youth who use active transportation to get to and from places (eg, school, park, mall, friend’s house).
% of children and youth who meet the Canadian Sedentary Behaviour Guidelines (5- to 17-year-olds: no more than 2 hours ofrecreational screen time per day). Note: the Guidelines currently provide a time limit recommendation for screen-related
pursuits, but not for non-screen-related pursuits.
Average percentile achieved on certain physical ﬁtness indicators based on the normative values published by Tomkinson
et al.41% of family members (eg, parents, guardians) 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 Global
Recommendations on Physical Activity for Health, which recommend that adults accumulate at least 150 minutes of moderateintensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity
throughout the week or an equivalent combination of moderate- and vigorous-intensity physical activity. % of family members(eg, parents, guardians) 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.
% of schools with active school policies (eg, daily PE, daily physical activity, recess, “everyone plays” approach, bike racks at
school, trafﬁc 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 the mandated amount of PE (for the given state/territory/
region/country). % of schools that offer physical activity opportunities (excluding PE) to the majority (>80%) of their students.
% of parents who report their children and youth have access to physical activity opportunities at school in addition to PE
classes. % of schools with students who have regular access to facilities and equipment that support physical activity(eg, gymnasium, outdoor playgrounds, sporting ﬁelds, multipurpose space for physical activity, equipment in good condition).
% 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 physicalactivity.
% of communities/municipalities that report they have infrastructure (eg, sidewalks, trails, paths, bike lanes) speciﬁcally
geared toward promoting physical activity.
% of children or parents who report having facilities, programs, parks and playgrounds available to them in their community.
% of children or parents who report living in a safe neighborhood where they can be physically active.
% of children or parents who report having well-maintained facilities, parks and playgrounds in their community that are safe
to use.
Evidence of leadership and commitment in providing physical activity opportunities for all children and youth. Allocatedfunds 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).
JPAH 15 Supplement 2, 2018

Very High HDI Country Physical Activity Grades for Children and Youth

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

Table 2

S301

Global Matrix 3.0 Grading Rubric
Corresponding number
for analysis

Grade

Interpretation

A+
A
A−
B+
B
B−
C+
C
C−
D+
D
D−
F
INC

94%–100%
We are succeeding with a large majority of children and youth (87%–93%)
80%–86%74%–79%We are succeeding with well over half of children and youth (67%–73%)
60%–66%54%–59%We are succeeding with about half of children and youth (47%–53%)
40%–46%34%–39%We are succeeding with less than half but some children and youth (27%–33%)
20%–26%
We are succeeding with very few children and youth (<20%)
Incomplete—insufﬁcient or inadequate information to assign a grade(2) behavioral score (Overall Physical Activity, Organized Sportand Physical Activity Participation, Active Play, Active Transportation, and Sedentary Behaviors), and (3) sources of inﬂuence score(Family and Peers, School, Community and Environment, andGovernment). Scores for each group of indicators were calculated
by summing the relevant interval data. INC grades were removed
and the scores were reweighted accordingly. Categorical variables(letter grades) were grouped into 1 of 4 levels (“A–B,” “C,” “D–F,”
and “No Grade”) based on the overall score. These categories werethen used to rank countries by letter grade/score and category levelin scatter plot data visualizations. Correlational analyses between
the 10 common indicators were performed using Spearman’s rankcorrelation coefﬁcients. Pairwise deletion was used to treat missing
data (INC) instead of other techniques (eg, listwise deletion) inorder to minimize the number of cases excluded from the analysis.
All statistical analyses were performed using R (version 3.4.1; The
R Foundation for Statistical Computing, Vienna, Austria). Several
packages were loaded to extend base R including corrplot,42
ggplot2,43 UpSetR,44 and VIM.45 In addition, descriptive statisticsof the qualitative information regarding the measurement of overall
physical activity were performed.

Results
The sociodemographic characteristics of the 30 very high HDI
countries are presented in Table 3. The HDI scores ranged from0.840 for the United Arab Emirates to 0.985 for Jersey. Chile wasthe country with the lowest gross national income per capita, thehighest Gini index (highest income inequality), and the highest
child poverty rate (0.225). Qatar had the highest gross national
income per capita, the lowest relative public health expenditure,and the highest Gender Inequality Index. Slovenia had the lowest
Gini index (least income inequality) and the lowest percentage ofurban population (49.8%). The life expectancy at birth was above
80 years for most of the countries (23 countries, 77%), with amaximum of 84.2 years for Hong Kong. Lithuania had a notably
lower life expectancy of 73.5 years compared with other countries.
The mean years of schooling ranged from 8.9 years in Portugal to

15
14
13
12
11
10
9
8
7
6
5
4
2
No Grade

13.3 years in the United Kingdom nations (England, Scotland, andWales). Finally, population density ranged from 3.2 people/km2 ofland area for Australia, to 6987.2 people/km2 of land area for HongKong. In summary, despite all 30 countries being within the very
high HDI category, countries varied substantially in othercharacteristics.
The 30 country grades for the 10 core Report Card indicators(300 grades or INC in total) and the average grades for each country
are shown in Table 4, and the corresponding descriptive information is presented in Table 5. In total, 233 letter grades and 67 INC
grades were assigned (Table 4). The country with the highest
average grade was Slovenia with “B,” and the countries with thelowest average grade were Chile and the United States with “D.”All 30 countries assigned a grade to Sedentary Behaviors, 29
countries (97%) to Overall Physical Activity, and 28 countries(93%) to Organized Sport and Physical Activity and to Active
Transportation. Active Play was the indicator with the largest
number of INC grades (n = 20), followed by Physical Fitness(n = 13), and Family and Peers (n = 13). The indicator with thehighest average grade was Community and Environment with “B−,” while the indicator with the lowest average grade was Overall
Physical Activity with “D−.” An average grade of “D+” wasobtained for the behavioral indicators combined, “C+” for thesource of inﬂuence indicators combined, and “C−” was the overall
average for the 233 grades. Qatar’s Report Card workgroupdecided not to evaluate Active Transportation and considered it“not applicable” because of unsafe road conditions and the hot
climate during most times of the year.56 Correlation analyses
showed that there were no relationships between the Overall
Physical Activity grade and any of the other 9 core indicator grade(results not shown). Frequency plots illustrating the distribution of
the overall 233 grades as well as the behavioral and the sources ofinﬂuence indicators are presented in Figures 1A and 1B, respectively. A normal distribution of the letter grades is evident in bothFigures 1A and 1B, with the mode being “C” for the 233 letter
grades overall, “D” for the behavioral indicators, and “B” for thesources of inﬂuence indicators.
A plot for the overall score for each country estimated from the
10 indicators is presented in Figure 2, and the behavioral and the

JPAH 15 Supplement 2, 2018

S302

JPAH 15 Supplement 2, 2018

0.939
0.896
0.92
0.847
0.878
0.925
0.909
0.865
0.895
0.897
0.926
0.975
0.917
0.903
0.985
0.848
0.924
0.915
0.855
0.843
0.856
0.909
0.89
0.901
0.884
0.913
0.885
0.84
0.92
0.909

Australia
Belgium
CanadaChile
Czech Republic
Denmark
England
Estonia
FinlandFranceGermany
GuernseyfHong KongJapan
Jerseyg
Lithuania
The Netherlands
New Zealand
PolandPortugal
Qatar
ScotlandSlovenia
South Korea
Spain
SwedenTaiwanh
United Arab Emirates
United States
Wales

26,00646,32632,87024,117
26,104
129,916
37,931
28,66434,541
32,77946,25145,582
66,20353,24537,931

54,26537,26842,822
41,24342,582
21,66528,14444,51937,931
26,362
38,86838,08545,000

0.121
0.044
0.158
0.137
0.091
0.542
0.131
0.053
0.067
0.081
0.048
0.232
0.203
0.131

2.6
8.3
7.6

0.116

0.12
0.073
0.098
0.322
0.129
0.041
0.131
0.131
0.056
0.102
0.066

GIIa

4.4
9.5
9.1
4.5
6.2
1.9
7.6
6.6
4.0
6.4
10.0

8.6

6.3
8.3
7.4
3.9
6.3
9.2
7.6
5.0
7.3
9.0
8.7

Public healthexpenditure(% of GDP)a
82.5
81.0
82.2
82.0
78.8
80.4
80.8
77.0
81.0
82.4
81.1
82.6
84.2
83.7
81.9
73.5
81.7
82.0
77.6
81.2
78.3
80.8
80.6
82.1
82.8
82.3
80.2
77.1
79.2
80.8

Life
expectancy
at birtha

9.5
13.2
13.3

12.7
11.9
12.5
11.9
8.9
9.8
13.3
12.1
12.2
9.8
12.3

11.6
12.5

13.2
11.4
13.1
9.9
12.3
12.7
13.3
12.5
11.2
11.6
13.2

Mean
years ofschoolinga

41.5
33.2

33.2
25.4
31.6
36.2
29.2
33.6

31.8
35.5

32.1
41.0
37.4
29.3

34.7
27.7
34.0
47.7
25.9
28.2
33.2
32.7
27.1
32.7
31.7
40.0

Gini
indexb

78.1
81.7

0.199
0.112

0.071
0.221
0.091
70.9
84.6
84.2

0.112

0.191
0.102
0.141
0.134
0.155

0.13
0.11
0.171
0.225
0.105
0.029
0.112
0.121
0.037
0.113
0.095

Child
poverty
rated

82.8
81.0
74.1
79.0
73.3
84.2

79.5

81.0
82.3
82.5

83.3
79.8
82.2
74.7
75.8
80.3
84.2

Globalfood security
indexc

84.7
82.6
79.7

67.2
83.6
86.3
60.8
61.6
98.9
79.7
49.8
83.5
77.6
85.4

100.0
91.9

89.4
97.5
80.8
89.4
73.4
87.1
79.7
69.5
83.8
86.4
74.1

Urban
population
percentagee

111
35
271

3
374
4
24
137
136
271
31
18
122
236
850
6987
348
845
46
506
18
124
113
221
271
103
526
93
24

Population
density(people/km2)f

Abbreviations: GDP, Gross Domestic Product; GII, Gender Inequality Index; GNI, Gross National Income; HDI, Human Development Index.
Sources of information: aUnited Nations Development Programme.8 b,fThe World Bank.46,47 cThe Economist Intelligence Unit.48 dOrganisation for Economic Co-operation and Development Child (OECD) WellBeing Data Portal.49 eUnited Nations, Department of Economic and Social Affairs.50 fFor Guernsey, the HDI sourced from the United Nations Economic and Social Commission for Asia and the Paciﬁc,51 the life
expectancy at birth, population size, and the population density sourced from the United States Central Intelligence Agency,52 and the Gini index sourced from the State of Guernsey.53 gFor Jersey, the HDI sourced
from the United Nations Economic and Social Commission for Asia and the Paciﬁc,51 and the life expectancy at birth, population size, and the population density sourced from the United States Central Intelligence
Agency,52 and the Gini index sourced from the State of Jersey.54 hFor Taiwan, the HDI, the GNI per capita, the life expectancy at birth, and the Gini index come from the National Statistics, Republic of China(Taiwan).55 For England, Scotland, and Wales, the ofﬁcial data for the United Kingdom were reported.

HDIa

GNI per
capitaa

Sociodemographic Information of the 30 Very High HDI Countries in the Global Matrix 3.0

Country

Table 3

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

Very High HDI Country Physical Activity Grades for Children and Youth

S303

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

Table 4 Grades Assigned to the 10 Core Physical Activity Indicators for the 30 Very High HDI Countries of the
Global Matrix 3.0
Australia
Belgium (Flanders)
CanadaChile
Czech Republic
Denmark
England
Estonia
FinlandFranceGermany
Guernsey
Hong KongJapan
JerseyLithuania
The Netherlands
New Zealand
PolandPortugal
Qatar
ScotlandSlovenia
South Korea
Spain
SwedenTaiwanUnited Arab Emirates
United States
Wales

PA

SP

AP

AT

SB

PF

FAM

SCH

COM

GOV

AVG

D−
F
D+
D−
D
D−
C−
D−
D
D
D−
D
C−
INC
D−
C−
C
D−
D−
D
D
F
A−
F
D
D+
F
F
D−
D+

B−
B
B+
D−
B−
A−
D+
C
C+
C−
B
C+
C
B−
INC
C
B
B
D
B−
D+
B
C+
C
B
B+
D−
INC
C
C+

INC
INC
D
INC
D−
INC
INC
F
C
INC
D−
INC
INC
INC
INC
INC
B
C+
INC
INC
INC
INC
D
INC
C−
INC
INC
INC
INC
C−

D+
C+
D−
F
C+
B+
C−
D
B+
C−
C−
D
B+
A−
D+
C−
B−
C−
C
C−
N/A
C
C
B+
B−
C
C−
INC
D−
D+

D−
C
D+
C−
D−
D+
D+
F
D−
D−
D−
C
C−
C−
C
C−
C−
D
D
C−
D+
F
B+
D
B+
C+
C−
C−
D
F

D+
INC
D
D
C+
INC
C−
INC
C
B−
INC
INC
D
A
D
C+
INC
INC
C−
C
INC
INC
A−
D+
INC
INC
B−
INC
C−
INC

C+
C+
C+
F
C+
INC
INC
D
B−
INC
B−
INC
D−
C−
C
D
INC
C
C−
C
INC
INC
B+
INC
INC
INC
INC
INC
INC
D

B+
B−
B−
D
B+
A−
B+
C+
A
B
B+
INC
C
B+
B−
C+
C
B−
B
A
C
INC
A
D+
C+
C+
B+
D−
D−
INC

A−
B
B+
B
B
B+
C
B
B+
INC
B+
INC
B
B−
C
C
INC
B
C
B
INC
B−
B
INC
INC
A
B+
INC
C
INC

D
B
C+
B−
C+
A−
INC
B
A−
C
INC
D
C
B
D
C
INC
B+
C+
B
B+
C
A
D
INC
B
B+
B+
INC
C+

C−
C
C−
D
C
B−
C−
D+
C+
C−
C
D+
C−
B−
D+
C−
C+
C
C−
C+
C−
D+
B
D+
C+
C+
C
D+
D
D+

Abbreviations: AP, Active Play; AT, Active Transportation; AVG, average; COM, Community and Environment; FAM, Family and Peers; GOV, Government; HDI,
Human Development Index; INC, incomplete grade; N/A, not applicable; PA, Physical Activity; PF, Physical Fitness; SB, Sedentary Behaviors; SCH, School;
SP, Organized Sport and Physical Activity Participation.

source of inﬂuence scores in Figures 3 and 4, respectively. For theoverall score, Slovenia ranked ﬁrst while Chile ranked 30th (seemore rankings in Figure 2). In terms of the grading completion, theUnited Arab Emirates had only 4 graded indicators that were
included in the calculation of this score, while 4 other countries(Slovenia, Finland, Czech Republic, and Canada) had all 10
indicators graded. For the behavioral score, Japan ranked ﬁrst
while Estonia ranked 30th (see more rankings in Figure 3). The
United Arab Emirates had only 2 out of 5 indicators, and Japan and
Qatar only had 3 graded indicators that were included in thecalculation of the behavioral score. Similar to the overall score,
Slovenia also ranked ﬁrst for the sources of inﬂuence score, while
Guernsey, with only one out of 4 graded indicators available,ranked 30th (see more rankings in Figure 4).
Finally, the description of the data sources used to inform theOverall Physical Activity grade for each country (except for Japanthat had an INC) are presented in Supplemental Material [available
online]. In total, 87 surveys or studies informed the grades of thevery high HDI countries, representing a total sample size of
1,005,989 children and youth. A total of 21 surveys/studies
used an objective measurement of physical activity, while 66
used a subjective method, mostly via self-administered questionnaires. Out of 21 surveys/studies that measured physical activity
objectively, 20 used accelerometry and one study used pedometry.
A minimum wear time for accelerometer ranged between 3 and 7
consecutive days, and 9 different accelerometer cut points wereapplied for analysis across 20 surveys/studies with the mostcommonly used cut points (n = 8) from Evenson et al.57 Regarding
the subjective measurement of physical activity, survey-speciﬁcquestionnaires were used in a signiﬁcant number of surveys(n = 35), followed by original or adapted versions of the HealthBehaviour in School-Aged Children questionnaire (n = 14),uniquely in European countries, the Global School-based Student
Health Survey questionnaire (n = 5), the Youth Risk Behavior
Surveillance System questionnaire (n = 4), the International Physical Activity Questionnaire (n = 3), and others (n = 5).

JPAH 15 Supplement 2, 2018

S304

Aubert et al

Table 5 Descriptive Statistics of the Grades by Indicator and Group of Indicators for the Very High Human
Development Index Countries of the Global Matrix 3.0

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

Overall Physical Activity
Organized Sport and Physical Activity Participation
Active Play
Active Transportation
Sedentary Behaviors
Physical Fitness
Family and Peers
SchoolCommunity and Environment
Government
Behavioral indicators
Sources of inﬂuence indicators
All indicators

Grade
count

Incomplete
gradesMean number
grade

SD

Mean letter
grade

Range

29
28
10
28
30
17
17
27
22
25
30
30
30

1
2
20
2
0
13
13
3
8
5
0
0
0

4.9
9
6.2
7.8
6.1
7.9
7.5
9.9
10.7
9.6
6.8
9.3
7.9

2.2
2.4
2.7
2.7
2.4
2.7
2.6
2.9
1.7
2.7
1.6
2
1.5

D−
C+
D+
C−
D+
C−
C−
C+
B−
C+
D+
C+
C−

F to A−D− to A−F to BF to A−F to B+D to AF to B+D− to A
C to A
D to AD− to B−D to A−
D+ to B

Note: Behavioral indicators = average of Overall Physical Activity, Organized Sport Participation, Active Play, Active Transportation, and Sedentary Behavior indicator
grades; source of inﬂuence indicators = average of Family and Peers, School, Community and Environment, and Government Strategies and Investments indicator grades.
Physical ﬁtness was not included in the behavioral indicators cluster. There are no missing grades for the bottom 3 rows because these scores are adjusted for
missing grades.

Figure 1 — Frequency plot by letter grade among 30 very high Human Development Index countries in the Global Matrix 3.0. (A) For the 10 core
indicators. (B) For the behavioral indicators and for the source of inﬂuence indicators. Note: Behavioral indicators = average of Overall Physical Activity,
Organized Sport Participation, Active Play, Active Transportation, and Sedentary Behavior indicator grades; source of inﬂuence indicators = average ofFamily and Peers, School, Community and Environment, and Government Strategies and Investments indicator grades. Physical ﬁtness was not includedin the behavioral indicators cluster.

Discussion
The objective of this paper was to present, describe, and compare
the Report Card grades from the 30 very high HDI countries andnations participating in the Global Matrix 3.0. A wide range of
grades was observed for most indicators across countries. These
30 countries are geographically distributed across Asia, Europe,
North America, Oceania, and South America and have very
different climatic, geographic, demographic, and cultural characteristics. Despite these contextual differences, most of these countries shared concerning low grades for Overall Physical Activity
and Sedentary Behaviors. No country was consistently leading nor
falling behind the others across the 10 common indicators, however, some countries showed greater or less success than others.

The characteristics of the most and the least successful countries are
discussed below, followed by a discussion of the ﬁndings for eachindicator, and an integrated discussion of the ﬁndings including thestrengths and limitations of this study.

Most Successful Countries
Slovenia had sufﬁcient data to inform the 10 indicators andobtained the best grades for Overall Physical Activity (“A−”),
Family and Peers (“B+”), and Government (“A”), as well as on
average (“B”); and shared the best grades for Sedentary Behaviors
with Spain (“B+”), and for School (“A”) with Finland and Portugal.
A notable feature of Slovenia is the importance of sport for theculture of this almost 30-year old country as “Slovenes tend to view

JPAH 15 Supplement 2, 2018

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

Very High HDI Country Physical Activity Grades for Children and YouthS305

Figure 2 — Plot of the overall score estimated for the 10 core indicators for the 30 very high Human Development Index countries of the Global Matrix
3.0. Note: The overall score was adjusted for missing and incomplete grades. The number in parenthesis shows the number of grades available for the
calculation of the score.

Figure 3 — Plot of the behavioral score estimated for the very high Human Development Index countries of the Global Matrix 3.0. Note: The overall
score was adjusted for missing and incomplete grades. The number in parenthesis shows the number of grades available for the calculation of the score.

sports as an effective tool in fostering national identity among
citizens and making successful global identity claims.”58 Every
April since 1987, a national school-based surveillance system ofphysical ﬁtness (named Sloﬁt) takes place, targeting the majority of

Slovenian school children and youth aged 6–19 years.59 Negative
trends in motor skills and physical ﬁtness were observed for over2 decades in Slovenia, but since 2011, these trends have been
reversed after the implementation of a health-oriented physical

JPAH 15 Supplement 2, 2018

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

S306

Aubert et al

Figure 4 — Plot of the source of inﬂuence indicators score for the very high Human Development Index countries of the Global Matrix 3.0. Note: The
overall score was adjusted for missing and incomplete grades. The number in parenthesis shows the number of grades available for the calculation of
the score. These estimates of sources of inﬂuence score are interpreted with a high degree of caution as they are likely imprecise estimates of sourcesof inﬂuence due to the level of missing data used to determine this score.

activity intervention program, which offers children 2 (optional)
additional hours of physical activity per week.60 The estimatedproportion of Slovenian children and youth meeting the recommended levels of daily physical activity is now high (over 80%),and this encouraging outcome seems to be the result of thecollective support for childhood physical activity from the government, the educational system, and the parents themselves.61
The next 2 most successful countries were Denmark and Japan
with an average grade of “B−.” The positive result for these 2
countries should be interpreted with caution as both had “INC”
grades for some indicators. Active Play, Physical Fitness, andFamily and Peers for Denmark, and Overall Physical Activity andActive Play for Japan were not graded due to the lack of data.
Nonetheless, Denmark was the country with the best grade for
Organized Sport and Physical Activity (“A−”), and also obtained agrade of “A−” for both School and Government indicators. Sport isan important part of the Danish culture, and considered important
not only for individual and population health, but also in relation toissues such as social inclusion and community cohesion.62 Despite
Denmark performing rather well on the strategic and politicallevels, low grades were attributed to Overall Physical Activity(“D−”) and Sedentary Behaviors (“D+”), indicating an implementation gap between the governmental and individual levels.63
Japan had the best grades for Active Transportation (“A−”)and Physical Fitness (“A”), and had no grades lower than “C−.” Infact, Japan has a highly established “walking to school practice”
that has been implemented since the School Education Act enforcement order, enacted in 1953, stating that public elementary schools
should be sited within no more than 4 km, and for public juniorhigh schools no more than 6 km from the student’s home. This
policy is still successful today at promoting active transportation

among Japanese children and youth.64 The Physical Fitness grade
was assigned based on the performance of Japanese children andyouth on the 20-m shuttle run test. On average, Japanese children
were in the 90th percentile,65 based on age- and sex-speciﬁc
international normative data.41 The Organized Sport and Physical
Activity Participation (graded “B−”) and the favorable School
environment (graded “B+”) may explain this high level of physicalﬁtness; however, this is speculative and more research is necessary.
It was observed that only a minority of time in physical education
classes was spent in MVPA (27.3%/45 min/class) in Japanese
primary school students.66

Least Successful Countries
Chile and the United States were the 2 countries with the lowest
average grade: “D.” They were followed by Guernsey, Jersey,
Scotland, South Korea, the United Arab Emirates, and Wales, who
obtained an average grade of “D+.” Chile had the lowest grades for
Active Transportation (“F”), Family and Peers (“F”), and shared
the lowest grades for Organized Sport and Physical Activity with
Taiwan (“D−”), and for Physical Fitness with Canada, Hong Kong,and Jersey (“D”). In Chile’s ﬁrst Report Card (2016), all indicators
had low grades, and data from different surveys indicated that there
were consistent disparities across genders, socioeconomic status,and school types.67 In 2018, Chile’s grades remained low incomparison with the ﬁrst Report Card in 2016 but progress wasmade on environmental and policy aspects,68 raising hope thatthese improvements will positively affect behavioral indicators in
the future.
The low average grade of the United States should be interpreted carefully because 3 indicators were assigned an “INC”

JPAH 15 Supplement 2, 2018

Very High HDI Country Physical Activity Grades for Children and Youthgrade: Active Play, Family and Peers, and Government. The UnitedStates shared the lowest grades with the United Arab Emirates for
School (“D−”), and the Community and Environment (“C”) withEngland, Jersey, Lithuania, and Poland. Overall, none of theindicators were graded above “C” in the United States. This is
the third Report Card for the United States, and the grade for
Overall Physical Activity (“D−”) remained consistent with the2014 and 2016 Report Card.69,70 Similarly to Chile, major disparities in physical activity participation across gender, race/ethnicity, age, and socioeconomic status were observed.71

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

Overall Physical Activity
Among the 30 very high HDI countries, only Japan assigned an“INC” grade for Overall Physical Activity. The grades ranged from“F” to “A−” for this indicator; however, Slovenia was the only
country with a “good” grade (“A−”), and all the other countries’
grades fell between “F” and “C.” Five countries received an “F”(Flanders, Scotland, South Korea, Taiwan, and the United ArabEmirates), 4 countries assigned “C” grades (England, Hong Kong,
Lithuania, and The Netherlands), and all the remaining countries
had a “D−,” “D,” or “D+.” The comparison and interpretation of theOverall Physical Activity grades should be conducted carefully
given the important variation in the methods used to measure
Overall Physical Activity between the countries, as seen in
Supplemental Material [available online]. In fact, objective data
were used in 13 of 29 countries with an Overall Physical Activity
letter grade, and subjective data in 27 countries (11 countries
combined subjective and objective data to inform their Overall
Physical Activity indicator). In addition, even among the subjectiveor the objective data, the methods differed largely in terms of
instruments, analysis, age range, sample size, and representativeness of samples.
The correlational analyses showed that there was no relationship between Overall Physical Activity and the physical activityrelated indicators (Organized Sport and Physical Activity, Active
Play, and Active Transportation). For example, only 56% ofchildren and 33% of adolescents met the international physicalactivity recommendations in The Netherlands despite a high levelof Organized Sport and Physical Activity, Active Play, and Active
Transportation (graded “B,” “B,” and “B−,” respectively).72 A
similar pattern was observed in Belgium (Flanders), Denmark,Scotland, South Korea, and Spain where Overall Physical Activity
was graded “F” or “D/D−” despite the fact that grades between “A”
and “C” were assigned to Organized Sport and Physical Activity,
Active Play, and Active Transportation (note: an “INC” grade was
assigned to Active Play for Flanders, Denmark, Scotland, andSouth Korea).63,73–76 The opposite situation was observed in
Slovenia where Overall Physical Activity was graded “A−,” while
Organized Sport and Physical Activity, Active Play, and Active
Transportation were graded “C+,” “D,” and “C,” respectively.
The absence of a relationship between Overall Physical Activity and other behavioral indicators can potentially be explained by
the aforementioned differences in methods used to measure these
indicators and the diversity of benchmarks between countries. The
recommended benchmark for physical activity was “% of children
and youth [ . . . ] who accumulate at least 60 minutes MVPA per day
on average, or % of children and youth meeting the guidelines on atleast 4 days a week (when an average cannot be estimated)”(Table 1). The available data in each country did not necessarily
allow them to use either of these benchmarks strictly whenestimating the prevalence of physically active children and youth

S307

in their sample. For example, in France, a “high level of physicalactivity” corresponded to engage in physical activity 5 or moredays a week, and the regular use of active transportation, for 6- to
10-year olds (reported by the parents); and practicing a MVPA atleast 5 days a week for 11- to 17-year olds (self-reported).77 While
in England’s 2018 Report Card, the percentage of children andyouth accumulating at least 1 hour of MVPA 7 days a week wasevaluated.78 In addition, among the countries where objective
methods were used to measure physical activity, the estimatednumber of children meeting the physical activity guidelines could
also have been signiﬁcantly affected by the cutoff point that deﬁnes
the count per minute threshold for MVPA.79 Although the majorityof studies included in the Global Matrix 3.0 used the Evenson
cutoff point,57 several studies used different ones. For example, theFreedson cutoff point80 was used in Hong Kong, while the Puyau
cutoff point81 was used in Canada (Supplemental Material [available online]).
Notwithstanding the presented methodological issues acrosscountries, 29 out of 30 very high HDI countries assigned a letter
grade to the Overall Physical Activity indicator, and for 28 of them,this grade was between “C” and “F,” with an average of “D−.”
These results are consistent with the current literature. A systematic
review of physical activity in European children and adolescents
found that 5% to 47% of children and adolescents when measured
subjectively, or 0% to 60% of children and adolescents whenmeasured objectively, achieved the recommended levels of physical activity.82 In another study describing objectively measured
physical activity and sedentary time patterns in children and youth
in 10 countries (9 very high HDI countries and Brazil), only 9% ofboys and 2% of girls accumulated ≥60 minutes of MVPA on allmeasured days.35 The present study provides additional evidence
that the situation regarding the physical activity of children andyouth is very concerning in very high HDI countries, and public
investment to implement effective interventions for increasing
physical activity opportunities is needed urgently. Unless a major
shift to a more active lifestyle happens soon, a high rate ofpremature noncommunicable diseases can be anticipated when
this generation of children will reach adulthood.

Organized Sport and Physical Activity
Most of the countries assigned a letter grade to Organized Sport andPhysical Activity, excepting Jersey and the United Arab Emirates.
With an average grade of “C+,” Organized Sport and Physical
Activity was the most successful behavioral indicator in the very
high HDI countries. Only 3 countries had a low grade for thisindicator: Chile (“D−”), Taiwan (“D−”), and France (“C−”); while
12 countries had relatively higher grades (“B+,” “B,” and “B−”)behind the lead of Denmark (“A−”). In Canada, Organized Sportand Physical Activity was the only behavioral indicator with a highgrade (“B+”),83 in which the high participation rate (77%) has been
relatively stable since 2005.84 Similarly, Organized Sport andPhysical Activity was also the highest graded indicator in Sweden.85 In relation to its geographical and population size, Sweden isconsidered as one of the world’s most sporting nations: out of the 7
million inhabitants between the ages of 7 and 70, more than 3
million were active members of sport clubs and more than 2 million
were competing regularly in 2012.86 However, as presented before,
these high rates of sport participation were not associated with a
sufﬁcient level of physical activity in the population.
Given that the benchmark for Organized Sport and Physical
Activity (“% of children and youth who participate in organized

JPAH 15 Supplement 2, 2018

S308

Aubert et alsport and/or physical activity programs”) does not specify intensity, duration, or frequency, we are missing important contextual
information of this indicator. These characteristics should be
evaluated to estimate the dose of physical activity associatedwith sport participation among children and youth. However,the popularity of sport among children and youth from very
high HDI countries suggests that increasing organized sport opportunities and accessibility could be a strategic solution to address
the prevalence of childhood physical inactivity in these countries.
Further research focusing on this indicator is needed to evaluate if
the available organized physical activity opportunities are indeed
saturated. Moreover, are all countries providing free or affordable
and appealing physical activity and sport participation opportunities for the entire youth population including different age,gender, socioeconomic, ethnic, and special population groups(eg, children with learning and/or physical disabilities)?

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

Active PlayThe main ﬁnding concerning Active Play was the amount of
missing data: 20 out of the 30 very high HDI countries assigned
an “INC” grade to this indicator. Among the 10 countries with aletter grade, The Netherlands attained the highest grade (“B”);
Estonia the lowest grade (“F”); and the 8 remaining countries had“C”s or “D”s. The average grade of “D+” for this indicator suggeststhat there is a low level of engagement in this behavior, and/or that
researchers were not able to detect it with the measurement
instruments they used. Indeed, valid and reliable tools to assess
active play are largely limited.87 In the Czech Republic, Active
Play was measured using self-reports of unstructured/unorganizedactive play for at least 2 hours per day88; while in New Zealand,
surveys asked parents/guardians or youth report to indicate if thechildren or youth had been active while playing (on their own orwith others) in the last 7 days, if they had been active while playing
for at least 7 hours in the last 7 days, and if they were allowed to goout on their own in the neighborhood.89 The development ofstandardized tools for the measurement of Active Play is challenged by the need for consensus on a deﬁnition. In a recent
systematic review synthesizing the literature to identify key concepts used to deﬁne and describe active play among young
children, Truelove et al87 proposed the following deﬁnition: “aform of gross motor or total body movement in which young
children exert energy in a freely chosen, fun, and unstructured
manner.” But a consensus deﬁnition needs to be ofﬁcially internationally agreed upon and acknowledged to advance the development and acceptance of standardized measurement tools.

Active Transportation
For Active Transportation, the grades ranged from “A−” (Japan) to“F” (Chile), with an average of “C−.” Qatar and the United ArabEmirates were the only 2 countries that did not assign a letter grade
to this indicator. Interestingly, 3 of the 4 countries from Eastern
Asia are leading this indicator: Japan (“A−”), Hong Kong (“B+”),and South Korea (“B+”). The successful school policy that has
been identiﬁed underlying this high prevalence of active transportation among children and youth in Japan was discussed previously
in this paper. In Hong Kong, a high proportion of children using
active transportation can be explained by the very high population
density of the city: most districts are highly self-contained sochildren usually attend schools close to their home.90 Similarly,
because most students live within 10-minute walking distance to/from school, national data showed that active commuting isprevalent in South Korea: 79.4% of children and youth reported
that they take active modes of transport to/from places.75 Previous
research has shown that active transportation is associated withincreased physical activity91; however, the Active Transportation
indicator was not correlated with Overall Physical Activity amongchildren in very high HDI countries in this study. Similar to
Organized Sport and Physical Activity and Active Play, thebenchmark for this indicator does not indicate duration or intensityof activity. Therefore, it is not possible to evaluate the extent towhich this indicator is contributing to the Overall Physical Activityof children and youth.

Sedentary Behaviors
Sedentary behavior corresponds to any waking behavior characterized by an energy expenditure ≤1.5 metabolic equivalents, while
in a sitting, reclining, or lying posture.92 For example, in children
and youth, it includes to the use of electronic devices while sitting,reclining, or lying, as well as reading, writing, or drawing while
sitting.92 While reading is associated with positive outcomes suchas higher academic achievement, screen time, often used as a proxyfor sedentary behavior in research, has been shown to be associatedwith a variety of negative health outcomes among children andyouth.93 For this reason, guidelines focusing speciﬁcally on screen
time were developed for the ﬁrst time in Canada in 2011, recommending limiting screen time to 2 hours daily for the 5- to 17-year
olds.94 Consistent with the current guidelines, the benchmark for
Sedentary Behaviors was solely based on screen time: “% ofchildren and youth who meet the Canadian Sedentary Behaviour
Guidelines (5- to 17-year-olds: no more than 2 hours of recreational
screen time per day).”
Sedentary Behaviors was the only indicator without any“INC” grades. Estonia, Scotland, and Wales were the 3 countries
with the lowest grade for this indicator (“F”), while Slovenia andSpain had the highest grade (“B+”). The remaining countries all
had “C”s or “D”s, and the average for this indicator was “D+.” In
total, only 5 out of the 30 very high HDI countries had a grade of“C” or higher. A small methodological difference was observed
between the very high HDI as few countries such as Estonia,
France, and Sweden reported the percentage of children and youth
who had less than 2 hours (<2 h/d) of daily screen time, while mostof the countries reported those spending 2 hours or less (≤2 h/d) infront of a screen. Another potential source of bias was not taking
into account the potential multitasking use of screens (eg, using aphone while watching a movie) as it was the case for France, which
could have led to an overestimation of screen time.77 Despite thesepotential methodological issues, the grades observed for thisindicator are extremely concerning among the very high HDI
countries. In Estonia, the prevalence of children meeting the screen
time recommendation was estimated as low as 7%.95 The development of more effective interventions targeting the reduction of
screen time among children and youth in very high HDI countries
should be a public health priority.

Physical Fitness
This is the ﬁrst time that Physical Fitness has been evaluated in the
Global Matrix. Physical ﬁtness corresponds to a state characterized
by an ability to perform daily activities with vigor, and a demonstration of traits and capacities that are associated with a lower riskof the premature development of diseases associated with physical

JPAH 15 Supplement 2, 2018

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

Very High HDI Country Physical Activity Grades for Children and Youth

S309

inactivity.96 The health-related components of physical ﬁtness are
cardiorespiratory endurance, muscular endurance, muscularstrength, body composition, and ﬂexibility.97 A recent systematic
review of the relationship between the 20-m shuttle run performance and health indicators among children and youth found that
performance on this test was associated with favorable indicators of
adiposity, and some indicators of cardiometabolic, cognitive, andpsychosocial health in boys and girls, and concluded that physicalﬁtness can be used as a holistic indicator of population health inchildren and youth.98
The benchmark for this indicator was the average percentile
achieved on certain health-related physical ﬁtness component
based on the normative values published by Tomkinson et al.41
On average, Physical Fitness was graded “C−.” The highest grade
was obtained by Japan (“A”), closely followed by Slovenia (“A−”);and 4 other countries (Canada, Chile, Hong Kong, and Jersey)
shared the lowest grade (“D”). An “INC” grade was assigned toPhysical Fitness in 13 countries. Various health-related physicalﬁtness components and different normative values were used to
calculate the percentile achieved by their sample of children andyouth and inform this indicator from one country to another. For
example, in Hong Kong this indicator was graded based on peakoxygen consumption, estimated with the performance on the 20-m
shuttle run performance among 9- to 17-year olds99; Jersey had dataon cardiorespiratory ﬁtness, muscular strength, muscular endurance, ﬂexibility, and motor fundamental movement skills development for school-aged children.100 Lithuania had data on endurance,
lower-body muscular power, upper-body muscular endurance, andlower-body muscular endurance for 11- to 18-year olds. Given
these signiﬁcant variations, the comparison of the Physical Fitness
indicator between very high HDI countries is compromised and thishighlights the need for developing international standardized measurements of health-related physical ﬁtness components.

Wales. The United Arab Emirates and the United States had thelowest grade (“D”), and Finland and Portugal shared the best gradefor School (“A”). A variation in data was used to inform thisindicator within the countries. In Finland, 87% of the schools
participated in the national Finnish Schools on the Move program.
This program aims at achieving more pleasant and active schooldays for children and encourages schools to increase physicalactivity during the schoolday as well as commuting.104 In Portugal,
physical education classes are mandatory for all students frompreschool to 12th grade. The time allocated to physical education
classes ranges from 90 to 150 minutes per week over 2 or
3 sessions/wk, and these classes are taught by a certiﬁed physicaleducation teacher. In addition, 85% of Portuguese schools offer
school clubs under the supervision of a physical education teacher,including competitions within and between schools.105 The correlational analyses did not ﬁnd an association between the School andthe Overall Physical Activity indicators, but similarly to otherindicators, the heterogeneity of data used to inform the School
indicator is potentially affecting this relationship.
A review of the relationship between academic performanceand participation in school-based physical activities, including
physical education, free school-based physical activity, and school
sports, found that adding time to academic or curricular subjects by
taking time from physical education programs does not enhance
grades in the corresponding academic subjects, and could be
detrimental to health.106 On the contrary, the authors also suggested
that more time can be allocated to physical activity from othersubjects without the risk of hindering students’ academic achievement.106 These ﬁndings suggest that the school environment,
policy, and curriculum have the potential to increase physicalactivity among children and youth, and more speciﬁc interventions
targeting the creation of daily physical opportunities at school need
to be developed in very high HDI countries.

Family and Peers

Community and Environment

Similarly to Physical Fitness, 13 countries assigned an “INC” grade
to the Family and Peers indicator. On average, this indicator was
graded “C−,” with Slovenia having the highest grade (“B+”) andChile having the lowest grade (“F”). Parental support and signiﬁcantothers support has been identiﬁed as 2 of the 16 correlates that areconsistently associated with physical activity of children and/or
adolescents in a systematic review of reviews.101 Because of thecomplexity of this indicator, several benchmarks were proposed for
its evaluation (Table 1), and measurement variations were observed.
In Poland, the grade was based on self-report of their parents’(material, emotional) support to their physical activity participation,
on self-report of their parents’ regular participation in physicalactivity, and on the prevalence of youth who declared being
regularly physically active with their father, their mother, and theirsiblings.102 In Germany, the prevalence of parents regularly participating in physical activity and the prevalence of children feeling thatthey receive positive support from their parents and friends to bephysically active informed the Family and Peers indicator.103 Theseﬁndings show that there is still a need for an established deﬁnition of
Family and Peer Inﬂuence, and then standardized and validated
methods of measurement for the Family and Peers indicator.

With an average of “B−,” Community and Environment was thehighest graded indicator of the 10 core indicators among the 30
very high HDI countries. The lowest grade for this indicator was“C,” shared by 5 countries (England, Jersey, Lithuania,
Poland, and the United States), and the highest grade, “A,” wasassigned by Sweden. Eight countries assigned an “INC” grade forthis indicator. With an “A−,” Australia was the second mostsuccessful country for this indicator. In the Australia’s 2018 Report
Card, parent-report data showed that most of youth were not facedwith problematic trafﬁc in their home or school neighborhood, hadaccess to good roads and footpaths and to public transport in theirneighborhood, had a park or playground near their home, and lived
in a safe neighborhood.107 In Taiwan, where this indicator was
graded “B+,” 81% of 13- to 17-year olds felt that there were
sufﬁcient exercise facilities in their neighborhood, and they reported spending an average of 9.7 minutes to reach their primary
exercise facilities.108 The lack of signiﬁcant correlation between
this indicator and the Overall Physical Activity does not align withsome of the research available on access to facilities.101 For
Community and Environment, in accordance with previous Global
Matrices,36,38 the available evidence from this indicator may
suggest that the characteristics of the built environment potentiallyinﬂuencing the physical activity of children are already meeting thecriteria to be considered favorable in the very high HDI countries.
This indicates that having favorable environmental infrastructurealone is not sufﬁcient to promote physical activity in very high HDI

SchoolThe School indicator had an average of “C+,” and only 3 countries
had an “INC” grade for this indicator: Guernsey, Scotland, and

JPAH 15 Supplement 2, 2018

S310

Aubert et al

countries. Social factors such as family, home, school, and community are also important to promote physical activity amongchildren and youth.

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

Government
The average grade for the Government indicator was “C+,” and thegrades ranged from “A” (Slovenia) to “D” (Australia, Guernsey,
Jersey, and South Korea). Five countries assigned an “INC” grade
to this indicator. With the exception of the 4 countries with a “D,”all the other very high HDI countries obtained a favorable grade(“C” or higher) for the Government indicator. Despite the recommended benchmark for this indicator, Government grades were
informed by different types of data in different countries. For
example, in Wales, 21 policy documents assessed across different
sectors including Health, Sport, Education, Environment, Transport, and Urban Design/Planning were evaluated using the HealthEnhancing Physical Activity Policy Audit Tool, obtaining a ﬁnal
score of 54% that was converted to a letter grade of “C+.”109
In some other countries that did not have relevant quantitative data,
a letter grade was graded primarily based on expert opinion.
Although most countries reported government physical activity
strategies and policies, the absence of a relationship between the
Government grades and the Overall Physical Activity grades andthe mostly low behavioral grades suggest that these actions are notsingularly effective at increasing the prevalence of MVPA amongchildren and youth.

Integrated Discussion
Generally, higher grades were reported for the source of inﬂuence
indicators in comparison with the behavioral indicators among the
30 very high HDI countries integrated in this study. The average
grade for the behavioral indicators was “D+” (ranging from “B−” to“D−”), while the average grade for the sources of inﬂuence
indicators was “C+” (ranging from “A” to “D”). This ﬁnding is
consistent with previous Global Matrices,36,38 and may be partiallyexplained by the fact that more than half of the countries thatparticipated in the Global Matrix 1.0 and 2.0 belonged to the very
high HDI category.
Japan, The Netherlands, and Slovenia had the highest behavioral score, while Estonia, Chile and the United Arab Emirates had
the lowest score (Figure 3). This score was calculated based on thegrades for 5 indicators, and most of the countries had 4 to 5 letter
grades to inform the score, with the exception of the United ArabEmirates with only 2 letter grades, and Qatar, Jersey, and Japan
with only 3 letter grades. The amount of “INC” grades for these 4
countries questions the accuracy of their ranking, in particular forJapan, in the leading position. For the sources of inﬂuence score,
Slovenia, Denmark, and Finland led the ranking, while the UnitedStates, South Korea, and Guernsey ranked at the bottom (Figure 4).
While the calculation of the source of inﬂuence score was based on
the letter grades for 4 indicators, 8 countries had only 2 letter grades
to inform this score, and Guernsey, The Netherlands, and Spain had
only one. The amount of “INC” grades challenges the correctnessof this classiﬁcation, in particular for the 3 countries with only one
source of inﬂuence indicator graded. The comparison of thesegroups of indicators suggests that the adequate to good grades
observed for the source of inﬂuence indicators are not translated ingood behavioral grades for the very high HDI countries.
In total, 24 countries had 3 or less “INC” grades, but 6
countries were missing data to grade 4 to 6 indicators. Including

countries with a signiﬁcantly large number of “INC” grades in the
Global Matrix 3.0 is a limitation to this study as it limits thecomparisons. For example, the United Arab Emirates had 6 “INC”
grades,110 Guernsey had 5 “INC” grades,111 and Qatar had 4 “INC”
grades, and a “not applicable” for Active Transportation.56 Anothermajor limitation of this study is the diversity of the data that wasused to inform the 10 core indicators, challenging the comparativeness of the grades within the same indicator. Two identicalgrades for the same indicator can potentially reﬂect very different
situations from one country to another. An alternative approach
would have been to exclude the countries with insufﬁcient datafrom the Global Matrix 3.0, and to have assigned “INC” grades toall the countries with data that were not ﬁtting exactly with thebenchmarks for each indicator. Yet, this strategy would haveconsiderably reduced the number of countries and indicators
included in the analyses of this study and decrease the relevanceof conducting international comparisons within an HDI category.
Finally, a loss of information potentially occurs when translating
original data to a letter grade, as letter grades provide less information than continuous variables.
The main strength of this study is the large number ofparticipating countries who adopted the harmonized data gathering,assessing, and grading process, and the quantity of data that are
informing the international physical activity comparisons. This was
possible as a result of the inclusive strategy adopted by AHKGA.
This project offers the opportunity to paint a picture of thecharacteristics of childhood physical activity in each country, as
determined and explained by a diverse group of experts within eachcountry. In addition, despite the presented methodological issues,
this study allows the identiﬁcation of major trends concerning thecharacteristics of the physical activity of children and youth amongvery high HDI countries. The need for the development and theinternational adoption of standardized methods to conceptualize
and measure the 10 indicators was also highlighted in this paper.
An “INC” grade can be useful for advocacy in individual countries
in future cards, and the Global Matrix project has the potential toinﬂuence the physical activity national surveillance systems in the
short to long term. Finally, the development of a national Report
Card of physical activity for children and youth, and the participation in the Global Matrix initiative, contributes to raising awarenesson the childhood physical inactivity issue nationally and internationally, building capacity within participating countries, andpotentially inﬂuencing the creation of physical activity opportunities in the future.

Conclusion
This analysis and comparison of the Global Matrix 3.0 grades
provide a comprehensive summary of the level and context of thephysical activity of children and youth among the participating
very high HDI countries. While methodological limitations andresearch gaps were identiﬁed, this work allowed the portrayal ofmajor trends across the 10 physical activity indicators. The majority of very high HDI countries had better grades on the sources ofinﬂuence levels, but this was not translated in positive outcomes
concerning childhood physical activity and sedentary behavior,indicating an implementation gap between the policy/governmental and individual level. This paper provides additional evidence
that the situation regarding physical activity in children and youth
living in very high HDI countries is extremely concerning. Strategic public investments to implement effective interventions withinfamilies, communities, and schools to increase physical activity

JPAH 15 Supplement 2, 2018

Very High HDI Country Physical Activity Grades for Children and Youth

opportunities are needed. Unless a major shift to a more active
lifestyle happens soon, a high rate of noncommunicable diseases
can be anticipated when this generation of children will reachadulthood.
Acknowledgments
The authors would like to acknowledge the then Active Healthy Kids
Canada (now ParticipACTION) for developing the Report Card methodology, and the AHKGA for modifying and standardizing the benchmarks
and grading rubric. The authors are indebted to each country’s Report Card
leaders, Research Work Group, and all other members of their Report Card
Committees.

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

References
1. Nocon M, Hiemann T, Müller-Riemenschneider F, Thalau F, Roll S,
Willich SN. Association of physical activity with all-cause andcardiovascular mortality: a systematic review and meta-analysis.
Eur J Cardiovasc Prev Rehabil. 2008;15(3):239–246. PubMed
ID: 18525377 doi:10.1097/HJR.0b013e3282f55e09
2. Trost SG, Blair SN, Khan KM. Physical inactivity remains thegreatest public health problem of the 21st century: evidence,
improved methods and solutions using the ‘7 investments thatwork’ as a framework. Br J Sports Med. 2014;48(3):169–170.
PubMed ID: 24415409 doi:10.1136/bjsports-2013-093372
3. Blair SN. Physical inactivity: the biggest public health problem of
the 21st century. Br J Sports Med. 2009;43(1):1–2. PubMed ID:
19136507
4. Poitras VJ, Gray CE, Borghese MM, et al. Systematic review of therelationships between objectively measured physical activity andhealth indicators in school-aged children and youth. Appl Physiol
Nutr Metab. 2016;41(6 suppl 3):S197–S239. PubMed ID: 27306431
doi:10.1139/apnm-2015-0663
5. Janssen I, LeBlanc AG. Systematic review of the health beneﬁts ofphysical activity and ﬁtness in school-aged children and youth. Int J
Behav Nutr Phys Act. 2010;7(1):40. doi:10.1186/1479-5868-7-40
6. Kremer P, Elshaug C, Leslie E, Toumbourou JW, Patton GC, Williams
J. Physical activity, leisure-time screen use and depression amongchildren and young adolescents. J Sci Med Sport. 2014;17(2):183–187.
PubMed ID: 23648221 doi:10.1016/J.JSAMS.2013.03.012
7. McMahon EM, Corcoran P, O’Regan G, et al. Physical activity inEuropean adolescents and associations with anxiety, depression andwell-being. Eur Child Adolesc Psychiatry. 2017;26(1):111–122.
PubMed ID: 27277894 doi:10.1007/s00787-016-0875-9
8. United Nations Development Programme. Human Development
Index (HDI) Human Development Reports. 2016 http://hdr.undp.
org/en/content/human-development-index-hdi. Accessed April 7,
2018.
9. Land KC. The Human Development Index: objective approaches (2).
In: W. Glatzer, L. Camﬁeld, V. Møller, & M. Rojas (Eds.), Global
Handbook of Quality of Life. Dordrecht, The Netherlands: Springer;
2015:133–157.
10. Fasting MH, Nilsen TI, Holmen TL, Vik T. Life style related to bloodpressure and body weight in adolescence: cross sectional data fromthe Young-HUNT study, Norway. BMC Public Health. 2008;8(1):111. doi:10.1186/1471-2458-8-111
11. Ekelund U, Luan J, Sherar LB, et al. Moderate to vigorous physicalactivity and sedentary time and cardiometabolic risk factors inchildren and adolescents. JAMA. 2012;307(7):704. PubMed ID:
22337681 doi:10.1001/jama.2012.156

S311

12. Andersen LB, Harro M, Sardinha LB, et al. Physical activity andclustered cardiovascular risk in children: a cross-sectional study (TheEuropean Youth Heart Study). Lancet. 2006;368(9532):299–304.
PubMed ID: 16860699 doi:10.1016/S0140-6736(06)69075-2
13. Ekelund U, Anderssen SA, Froberg K, et al. Independent associations of physical activity and cardiorespiratory ﬁtness with metabolicrisk factors in children: the European Youth Heart Study. Diabetologia. 2007;50(9):1832–1840. PubMed ID: 17641870 doi:10.1007/
s00125-007-0762-5
14. Dumuid D, Maher C, Lewis LK, et al. Human Development Index,
children’s health-related quality of life and movement behaviors: acompositional data analysis. Qual Life Res. 2018;27(6):1473–1482.
PubMed ID: 29362939 doi:10.1007/s11136-018-1791-x
15. Lee I-M, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT.
Effect of physical inactivity on major non-communicable diseases
worldwide: an analysis of burden of disease and life expectancy.
Lancet. 2012;380(9838):219–229. PubMed ID: 22818936 doi:
10.1016/S0140-6736(12)61031-9
16. Ding Ding M, Lawson KD, Kolbe-Alexander TL, et al. The economic burden of physical inactivity: a global analysis of major noncommunicable diseases. Lancet. 2016;388(10051):1311–1324.
PubMed ID: 27475266 doi:10.1016/S0140-6736(16)30383-X
17. Konstabel K, Veidebaum T, Verbestel V, et al. Objectively measured
physical activity in European children: the IDEFICS study. Int J
Obes. 2014;38(suppl 2):S135–S143. doi:10.1038/ijo.2014.144
18. Sheldrick M, Tyler R, Mackintosh K, Stratton G. Relationshipbetween sedentary time, physical activity and multiple lifestylefactors in children. J Funct Morphol Kinesiol. 2018;3(1):15. doi:
10.3390/jfmk3010015
19. Baptista F, Santos DA, Silva AM, et al. Prevalence of the Portuguese
population attaining sufﬁcient physical activity. Med Sci Sports
Exerc. 2012;44(3):466–473. doi:10.1249/MSS.0b013e318230e441
20. Mielgo-Ayuso J, Aparicio-Ugarriza R, Castillo A, et al. Physicalactivity patterns of the Spanish population are mostly determined by
sex and age: ﬁndings in the ANIBES study. PLoS ONE. 2016;11(2):e0149969. doi:10.1371/journal.pone.0149969
21. Kokko S, Mehtälä A, Vasankari T, et al. Lasten ja nuorten liikuntakäyttäytyminen Suomessa–LIITU-tutkimuksen tuloksia 2016. Helsinki: Valtion liikuntaneuvosto; 2016;4.
22. Kalman M, Inchley J, Sigmundova D, et al. Secular trends inmoderate-to-vigorous physical activity in 32 countries from 2002
to 2010: a cross-national perspective. Eur J Public Health. 2015;
25(suppl 2):37–40. doi:10.1093/eurpub/ckv024
23. Tabak I, Mazur J, Nałe˛cz H. Family and individual predictors andmediators of adolescent physical activity. Health Psychol Rep. 2017;
4(4):333–344. doi:10.5114/hpr.2017.67522
24. Sigmund E, Sigmundová D, Badura P, Kalman M, Hamrik Z,
Pavelka J. Temporal trends in overweight and obesity, physicalactivity and screen time among Czech adolescents from 2002 to
2014: a national health behaviour in school-aged children study. Int J
Environ Res Public Health. 2015;12(9):11848–11868. PubMed ID:
26393638 doi:10.3390/ijerph120911848
25. Jodkowska M, Mazur J, Oblacińska A. Perceived barriers to physicalactivity among polish adolescents. Przegl Epidemiol. 2015;69(1):73–78. PubMed ID: 25862451 http://www.przeglepidemiol.
pzh.gov.pl/perceived-barriers-to-physical-activity-among-polishadolescents?lang=pl. Accessed May 30, 2018.
26. World Health Organization. Global Recommendation on Physical
Activity for Health. 2010. http://www.who.int/dietphysicalactivity/
factsheet_recommendations/en/. Accessed January 11, 2018.
27. Aguilar-Farias N, Martino-Fuentealba P, Carcamo-Oyarzun J, et al.
A regional vision of physical activity, sedentary behaviour and

JPAH 15 Supplement 2, 2018

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

S312

Aubert et alphysical education in adolescents from Latin America and the
Caribbean: results from 26 countries. Int J Epidemiol. 2018. 976–
986. doi:10.1093/ije/dyy033
28. Chiang P-H, Huang L-Y, Lee M-S, Tsou H-C, Wahlqvist ML. Fitness
and food environments around junior high schools in Taiwan and theirassociation with body composition: gender differences for recreational, reading, food and beverage exposures. PLoS ONE. 2017;12(8):e0182517. PubMed ID: 28771561 doi:10.1371/journal.pone.0182517
29. Wong SH, Huang WY, He G. Longitudinal changes in objectively
measured physical activity differ for weekdays and weekends among
Chinese children in Hong Kong. BMC Public Health. 2015;15(1):1310. doi:10.1186/s12889-015-2618-0
30. Tanaka C, Tanaka M, Okuda M, Inoue S, Aoyama T, Tanaka S.
Association between objectively evaluated physical activity andsedentary behavior and screen time in primary school children.
BMC Res Notes. 2017;10(1):175. PubMed ID: 28464957 doi:10.
1186/s13104-017-2495-y
31. Lee E-Y, Spence JC, Tremblay MS, Carson V. Meeting 24-Hour
Movement Guidelines for Children and Youth and associations
with psychological well-being among South Korean adolescents.
Ment Health Phys Act. 2018;14:66–73. doi:10.1016/J.MHPA.2018.
02.001
32. Sharara E, Akik C, Ghattas H, Makhlouf Obermeyer C. Physicalinactivity, gender and culture in Arab countries: a systematic assessment of the literature. BMC Public Health. 2018;18(1):639. PubMed
ID: 29776343 doi:10.1186/s12889-018-5472-z
33. Haroun D, ElSaleh O, Wood L. Dietary and activity habits in adolescents living in the United Arab Emirates: a cross-sectional study. Arab J
Nutr Exerc. 2017;1(2):85–100. https://knepublishing.com/index.php/
AJNE/article/view/1226/2672. Accessed May 24, 2018.
34. Zaabi MA, Shah SM, Sheek-Hussein M, Abdulle A, Junaibi AA,
Loney T. Results from the United Arab Emirates’ 2016 Report Cardon Physical Activity for Children and Youth. J Phys Act Health.
2016;13(11 suppl 2):S299–S306. doi:10.1123/jpah.2016-0312
35. Cooper AR, Goodman A, Page AS, et al. Objectively measured
physical activity and sedentary time in youth: the International
Children’s Accelerometry Database (ICAD). Int J Behav Nutr
Phys Act. 2015;12(1):113. doi:10.1186/s12966-015-0274-5
36. Tremblay MS, Gray CE, Akinroye K, et al. Physical activity ofchildren: a global matrix of grades comparing 15 countries. J Phys Act
Health. 2014;11(suppl 1):S113–S125. doi:10.1123/jpah.2014-0177
37. Colley RC, Brownrigg M, Tremblay MS. A model of knowledgetranslation in health. Health Promot Pract. 2012;13(3):320–330.
PubMed ID: 22447666 doi:10.1177/1524839911432929
38. Tremblay MS, Barnes JD, González SA, et al. Global Matrix 2.0:
Report Card grades on the physical activity of children and youth
comparing 38 countries. J Phys Act Health. 2016;13(11 suppl 2):
S343–S366. doi:10.1123/jpah.2016-0594
39. Active Healthy Kids Global Alliance. About us. 2016. https://www.
activehealthykids.org/about-us/. Accessed May 27, 2018.
40. Aubert S, Barnes JD, Adbeta C, Tremblay MS. Physical activity
Report Card grades for children and youth: result and analysis from49 countries. J Phys Act Health. 2018;15(suppl 2):S251–S273. doi:
10.1123/jpah.2018-0472
41. Tomkinson GR, Carver KD, Atkinson F, et al. European normativevalues for physical ﬁtness in children and adolescents aged 9–17 years: results from 2 779 165 Euroﬁt performances representing
30 countries [published online ahead of print November 30, 2017].
Br J Sports Med. doi:10.1136/bjsports-2017-098253
42. Wei T, Simko V, Levy M, Xie Y, Jin Y, Zemla J. Visualization of acorrelation matrix: corrplot. 2017. https://github.com/taiyun/
corrplot. Accessed July 5, 2018

43. Wickham H. ggplot2: Elegant Graphics for Data Analysis (2nd ed.).
New York, NY: Springer-Verlag; 2016.
44. Conway JR, Lex A, Gehlenborg N. UpSetR: an R package for thevisualization of intersecting sets and their properties. Bioinformatics.
2017;33(18):2938–2940. PubMed ID: 28645171 doi:10.1093/
bioinformatics/btx364
45. Kowarik A, Templ M. Imputation with the R package VIM. J Stat
Softw. 2016;74(7):1–16. doi:10.18637/jss.v074.i07
46. The World Bank. GINI index (World Bank estimate) | Data. 2017.
https://data.worldbank.org/indicator/SI.POV.GINI?view=map.
Accessed April 7, 2018.
47. The World Bank. Population density (people per sq. km of land area)| Data. 2016. https://data.worldbank.org/indicator/EN.POP.DNST.
Accessed June 27, 2018.
48. The Economist Intelligence Unit. Global Food Security Index:
overview.
2017.
https://foodsecurityindex.eiu.com/Index.
Accessed June 27, 2018.
49. Organisation for Economic Co-operation and Development. Poverty
rate.
2017.
https://data.oecd.org/inequality/poverty-rate.htm.
Accessed June 27, 2018.
50. United Nations Department of Economic and Social Affairs. Social
indicators/population growth and distribution. 2012. https://unstats.
un.org/unsd/demographic/products/socind/. Accessed June 27, 2018.
51. Hastings DA. Filling gaps in the Human Development Index:
ﬁndings for Asia and the Paciﬁc. 2009. https://www.unescap.org/
sites/default/ﬁles/wp-09-02.pdf. Accessed July 17, 2018.
52. The United States Central Intelligence Agency. The World Factbook, guide to country proﬁles. 2018. https://www.cia.gov/library/publications/resources/the-world-factbook/docs/proﬁleguide.html.
Accessed July 17, 2018.
53. State of Guernsey. Guernsey household income. 2015. https://www.
gov.gg/CHttpHandler.ashx?id=110715&p=0. Accessed July 17, 2018.
54. State of Jersey. Jersey household income distribution 2014/15.
2015. https://www.gov.je/SiteCollectionDocuments/Government
and administration/R Income Distribution Survey Report 2014-15
20151112 SU.pdf. Accessed July 17, 2018.
55. National Statistics Republic of China (Taiwan). Report on the surveyof family income and expenditure. 2017. https://eng.stat.gov.tw/ct.
asp?xItem=3417&CtNode=1596&mp=5. Accessed June 28, 2018.
56. Ibrahim I, Al Hammadi E, Sayegh S, et al. Results from Qatar’s 2018
Report Card on Physical Activity for Children and Youth. J Phys Act
Health. 2018;15(suppl 2):S400–S401. doi:10.1123/jpah.2018-0502
57. Evenson KR, Catellier DJ, Gill K, Ondrak KS, McMurray RG.
Calibration of two objective measures of physical activity forchildren. J Sports Sci. 2008;26(14):1557–1565. PubMed ID:
18949660 doi:10.1080/02640410802334196
58. Topič MD, Coakley J. Complicating the relationship between sportand national identity: the case of post-socialist Slovenia. Sociol SportJ. 2010;27(4):371–389. doi:10.1123/ssj.27.4.371
59. SLOﬁt. What is SLOﬁt. 2017. http://en.sloﬁt.org/. Accessed July 23,
2018.
60. Sember V, Starc G, Jurak G, et al. Results from the Republic ofSlovenia’s 2016 Report Card on Physical Activity for Children andYouth. J Phys Act Health. 2016;13(11, suppl 2):S256–S264. doi:
10.1123/jpah.2016-0294
61. Sember V, Morrison SA, Jurak G, et al. Results from Slovenia’s
2018 Report Card on Physical Activity for Children and Youth.
J Phys Act Health. 2018;15(suppl 2):S404–S405. doi:10.1123/jpah.
2018-0542
62. The ofﬁcial website of Denmark. Sports for everyone. 2016. https://web.archive.org/web/20170706132240/http://denmark.dk/en/
lifestyle/sport/sports-for-everyone/. Accessed July 24, 2018.

JPAH 15 Supplement 2, 2018

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

Very High HDI Country Physical Activity Grades for Children and Youth

63. Nørager Johansen DL, Neerfeldt Christensen BF, Fester M, et al.
Results from Denmark’s 2018 Report Card on Physical Activity forChildren and Youth. J Phys Act Health. 2018;15(suppl 2):S341–
S343. doi:10.1123/jpah.2018-0509
64. Mori N, Armada F, Willcox DC. Walking to school in Japan andchildhood obesity prevention: new lessons from an old policy. Am J
Public Health. 2012;102(11):2068–2073. PubMed ID: 22994195
doi:10.2105/AJPH.2012.300913
65. Tanaka C, Tanaka S, Inoue S, et al. Results from Japan’s 2018 Report
Card on Physical Activity for Children and Youth. J Phys Act Health.
2018;15(suppl 2):S375–S376. doi:10.1123/jpah.2018-0460
66. Tanaka C, Tanaka M, Tanaka S. Objectively evaluated physicalactivity and sedentary time in primary school children by gender,
grade and types of physical education lessons. BMC Public Health.
2018;18(1):948. PubMed ID: 30068319 doi:10.1186/s12889-0185910-y
67. Aguilar-Farias N, Cortinez-O’Ryan A, Sadarangani KP, et al.
Results from Chile’s 2016 Report Card on Physical Activity forChildren and Youth. J Phys Act Health. 2016;13(11 suppl 2):
S117–S123. doi:10.1123/jpah.2016-0314
68. Aguilar-Farias N, Miranda-Marquez S, Sadarangani KP, et al.
Results from Chile’s 2018 Report Card on Physical Activity forChildren and Youth. J Phys Act Health. 2018;15(suppl 2):S331–
S332. doi:10.1123/jpah.2018-0553
69. Dentro KN, Beals K, Crouter SE, et al. Results from the UnitedStates’ 2014 Report Card on Physical Activity for Children andYouth. J Phys Act Health. 2014;11(suppl 1):S105–S112. doi:10.
1123/jpah.2014-0184
70. Katzmarzyk PT, Denstel KD, Beals K, et al. Results from the UnitedStates of America’s 2016 Report Card on Physical Activity forChildren and Youth. J Phys Act Health. 2016;13(11, suppl 2):S307–
S313. doi:10.1123/jpah.2016-0321
71. Katzmarzyk PT, Denstel KD, Beals K, et al. Results from the UnitedStates 2018 Report Card on Physical Activity for Children andYouth. J Phys Act Health. 2018;15(suppl 2):S422–S424. doi:10.
1123/jpah.2018-0476
72. Takken T, de Jong N. Results from the Netherlands’s 2018 Report
Card on Physical Activity for Children and Youth. J Phys Act Health.
2018;15(suppl 2):S388–S389. doi:10.1123/jpah.2018-0513
73. Seghers J, De Baere S, Verloigne M, Cardon G. Results fromFlanders’ 2018 Report Card on Physical Activity for Children
and Youth. J Phys Act Health. 2018;15(suppl 2):S357–S359. doi:
10.1123/jpah.2018-0458
74. Hughes AR, Johnstone A, Bardid F, Reilly JJ. Results from
Scotland’s 2018 Report Card on Physical Activity for Children
and Youth. J Phys Act Health. 2018;15(suppl 2):S402–S403. doi:
10.1123/jpah.2018-0516
75. Oh J-W, Lim J, Lee S-H, et al. Results from South Korea’s 2018
Report Card on Physical Activity for Children and Youth. J Phys Act
Health. 2018;15(suppl 2):S409–S410. doi:10.1123/jpah.2018-0518
76. Roman-Viñas B, Zazo F, Martínez-Martínez J, Aznar-Laín S, SerraMajem L. Results from Spain’s 2018 Report Card on Physical
Activity for Children and Youth. J Phys Act Health. 2018;15(suppl 2):S411–S412. doi:10.1123/jpah.2018-0464
77. Aubert S, Aucouturier J, Ganière C, et al. Results from France’s 2018
Report Card on Physical Activity for Children and Youth. J Phys Act
Health. 2018;15(suppl 2):S360–S362. doi:10.1123/jpah.2018-0511
78. Standage M, Sherar L, Curran T, et al. Results from England’s 2018
Report Card on Physical Activity for Children and Youth. J Phys Act
Health. 2018;15(suppl 2):S347–S349. doi:10.1123/jpah.2018-0537
79. Gába A, Dygrýn J, Mitáš J, Jakubec L, Frömel K. Effect ofaccelerometer cut-off points on the recommended level of physicalS313

activity for obesity prevention in children. PLoS ONE. 2016;11(10):e0164282. doi:10.1371/journal.pone.0164282
80. Dowda M, Pate RR, Sallis J, Freedson PS. Accelerometer (CSA)
count cut points for physical activity intensity ranges in youth. Med
Sci Sports Exerc. 1997;29(5):72. https://journals.lww.com/acsmmsse/pages/articleviewer.aspx?year=1997&issue=05001&article=
00412&type=fulltext. Accessed July 26, 2018.
81. Puyau MR, Adolph AL, Vohra FA, Zakeri I, Butte NF. Predictionof activity energy expenditure using accelerometers in children. Med
Sci Sports Exerc. 2004;36(9):1625–1631. doi:10.1249/01.MSS.
0000139898.30804.60
82. Van Hecke L, Loyen A, Verloigne M, et al. Variation in populationlevels of physical activity in European children and adolescents
according to cross-European studies: a systematic literature review
within DEDIPAC. Int J Behav Nutr Phys Act. 2016;13(1):70. doi:10.
1186/s12966-016-0396-4
83. Barnes JD, Cameron C, Carson V, et al. Results from Canada’s 2018
Report Card on Physical Activity for Children and Youth. J Phys
Act Health. 2018;15(suppl 2):S328–S330. doi:10.1123/jpah.20180454
84. Canadian Fitness and Lifestyle Research Institute. Bulletin 02:
participation in organized physical activity and sport. 2016.
http://cﬂri.ca/document/bulletin-02-participation-organized-physicalactivity-and-sport. Accessed July 26, 2018.
85. Delisle Nyström C, Larsson C, Alexandrou C, et al. Results from
Sweden’s 2018 Report Card on Physical Activity for Children andYouth. J Phys Act Health. 2018;15(suppl 2):S413–S414. doi:10.
1123/jpah.2018-0519
86. RiksidrottsFörbundet. Sport in Sweden. 2012. www.rf.se. Accessed
July 26, 2018.
87. Truelove S, Vanderloo LM, Tucker P. Deﬁning and measuring active
play among young children: a systematic review. J Phys Act Health.
2017;14(2):155–166. doi:10.1123/jpah.2016-0195
88. Gába A, Rubín L, Badura P, et al. Results from the Czech Republic’s
2018 Report Card on Physical Activity for Children and Youth.
J Phys Act Health. 2018;15(suppl 2):S338–S340. doi:10.1123/jpah.
2018-0508
89. Smith M, Ikeda E, Hinckson E, et al. Results from New Zealand’s
2018 Report Card on Physical Activity for Children and Youth.
J Phys Act Health. 2018;15(suppl 2):S390–S392. doi:10.1123/jpah.
2018-0463
90. Huang WY, Wong SH, Wong MC, Sit CH, Sum RK, He G. Resultsfrom Hong Kong’s 2016 Report Card on Physical Activity forChildren and Youth. J Phys Act Health. 2016;13(11 suppl 2):
S169–S175. doi:10.1123/jpah.2016-0302
91. Larouche R, Saunders TJ, John Faulkner GE, Colley R, Tremblay M.
Associations between active school transport and physical activity,
body composition, and cardiovascular ﬁtness: a systematic review of
68 studies. J Phys Act Health. 2014;11(1):206–227. doi:10.1123/
jpah.2011-0345
92. Tremblay MS, Aubert S, Barnes JD, et al. Sedentary Behavior
Research Network (SBRN)—terminology Consensus Project process and outcome. Int J Behav Nutr Phys Act. 2017;14(1):75.
PubMed ID: 28599680 doi:10.1186/s12966-017-0525-8
93. Carson V, Hunter S, Kuzik N, et al. Systematic review of sedentary
behaviour and health indicators in school-aged children and youth:
an update. Appl Physiol Nutr Metab. 2016;41(6, suppl 3):S240–S265.
doi:10.1139/apnm-2015-0630
94. Tremblay MS, LeBlanc AG, Janssen I, et al. Canadian Sedentary
Behaviour Guidelines for children and youth. Appl Physiol Nutr
Metab. 2011;36(1):59–64. PubMed ID: 21326378 doi:10.1139/
H11-012JPAH 15 Supplement 2, 2018

Downloaded by UNIV OF STRATHCLYDE on 11/27/18

S314

Aubert et al

95. Mäestu E, Kull M, Mooses K, et al. Results from Estonian’s 2018
Report Card on Physical Activity for Children and Youth. J Phys Act
Health. 2018;15(suppl 2):S350–S352. doi:10.1123/jpah.2018-0456
96. Pate RR. The evolving deﬁnition of physical ﬁtness. Quest. 1988;
40(3):174–179. doi:10.1080/00336297.1988.10483898
97. Caspersen CJ, Powell KE, Christenson GM. Physical activity,
exercise, and physical ﬁtness: deﬁnitions and distinctions forhealth-related research. Public Health Rep. 1985;100(2):126–131.
http://www.ncbi.nlm.nih.gov/pubmed/3920711. Accessed May 13,
2018.
98. Lang JJ, Belanger K, Poitras V, Janssen I, Tomkinson GR, Tremblay
MS. Systematic review of the relationship between 20m shuttle run
performance and health indicators among children and youth. J Sci
Med Sport. 2018;21(4):383–397. PubMed ID: 28847618 doi:10.
1016/j.jsams.2017.08.002
99. Huang WY, Wong SH, Sit CH, et al. Results from Hong Kong’s
2018 Report Card on Physical Activity for Children and Youth. J
Phys Act Health. 2018;15(suppl 2):S370–S372. doi:10.1123/jpah.
2018-0468
100. Scriven J, Cabot J, Mitchell D, Kennedy D. Results from Jersey’s
2018 Report Card on Physical Activity for Children and Youth.
J Phys Act Health. 2018;15(suppl 2):S377–S378. doi:10.1123/jpah.
2018-0554
101. Sterdt E, Liersch S, Walter U. Correlates of physical activityof children and adolescents: a systematic review of reviews.
Health Educ J. 2014;73(1):72–89. doi:10.1177/0017896
912469578
102. Zembura P, Korcz A, Cieśla E, Gołdys A, Nałe˛cz H. Results from
Poland’s 2018 Report Card on Physical Activity for Children andYouth. J Phys Act Health. 2018;15(suppl 2):S395–S397. doi:10.
1123/jpah.2018-0540

103. Demetriou Y, Hebestreit A, Reimers AK, et al. Results from
Germany’s 2018 Report Card on Physical Activity for Children
and Youth. J Phys Act Health. 2018;15(suppl 2):S363–S365. doi:10.
1123/jpah.2018-0538
104. Kämppi K, Aira A, Halme N, et al. Results from Finland’s 2018
Report Card on Physical Activity for Children and Youth. J Phys Act
Health. 2018;15(suppl 2):S355–S356. doi:10.1123/jpah.2018-0510
105. Mota J, Santos R, Coelho-e-Silva MJ, Raimundo AM, Sardinha LB.
Results from Portugal’s 2018 Report Card on Physical Activity forChildren and Youth. J Phys Act Health. 2018;15(suppl 2):S398–
S399. doi:10.1123/jpah.2018-0541
106. Trudeau F, Shephard RJ. Physical education, school physical activity, school sports and academic performance. Int J Behav Nutr Phys
Act. 2008;5(1):10. doi:10.1186/1479-5868-5-10
107. Schranz N, Glennon V, Evans J, et al. Results from Australia’s 2018
Report Card on Physical Activity for Children and Youth. J Phys Act
Health. 2018;15(suppl 2):S315–S317. doi:10.1123/jpah.2018-0418
108. Chang C-K, Wu C-L. Results from Chinese Taipei (Taiwan)’s 2018
Report Card on Physical Activity for Children and Youth. J Phys Act
Health. 2018;15(suppl 2):S415–S416. doi:10.1123/jpah.2018-0555
109. Edwards LC, Tyler R, Blain D, et al. Results from Wales’ 2018
Report Card on Physical Activity for Children and Youth. J Phys Act
Health. 2018;15(suppl 2):S430–S432. doi:10.1123/jpah.2018-0544
110. Paulo MS, Nauman J, Abdulle A, et al. Results from the United ArabEmirates’ 2018 Report Card on Physical Activity for Children andYouth. J Phys Act Health. 2018;15(suppl 2):S419–S421. doi:10.
1123/jpah.2018-0543
111. Williams A, Whitman L, Le Page Y, Le Page C, Chester G, Sebire SJ.
Results from the Bailiwick of Guernsey’s 2018 Report Card on Physical
Activity for Children and Youth. J Phys Act Health. 2018;15(suppl 2):
S368–S369. doi:10.1123/jpah.2018-0539

JPAH 15 Supplement 2, 2018