Journal of Physical Activity and Health, 2016, 13 (Suppl 2), S343  -S366
http://dx.doi.org/10.1123/jpah.2016-0594© 2016 Human Kinetics, Inc.

ORIGINAL RESEARCH

Global Matrix 2.0: Report Card Grades on the Physical Activityof Children and Youth Comparing 38 Countries
Mark S. Tremblay, Joel D. Barnes, Silvia A. González, Peter T. Katzmarzyk, Vincent O. Onywera,
John J. Reilly, Grant R. Tomkinson, and the Global Matrix 2.0 Research TeamThe Active Healthy Kids Global Alliance organized the concurrent preparation of Report Cards on the physical activity of children and youth in 38 countries from 6 continents (representing 60% of the world’s population). Nine common indicators wereused (Overall Physical Activity, Organized Sport Participation, Active Play, Active Transportation, Sedentary Behavior, Family
and Peers, School, Community and the Built Environment, and Government Strategies and Investments), and all Report Cards
were generated through a harmonized development process and a standardized grading framework (from A = excellent, to F =failing). The 38 Report Cards were presented at the International Congress on Physical Activity and Public Health in Bangkok,
Thailand on November 16, 2016. The consolidated findings are summarized in the form of a Global Matrix demonstrating
substantial variation in grades both within and across countries. Countries that lead in certain indicators often lag in others.
Average grades for both Overall Physical Activity and Sedentary Behavior around the world are D (low/poor). In contrast, theaverage grade for indicators related to supports for physical activity was C. Lower-income countries generally had better gradeson Overall Physical Activity, Active Transportation, and Sedentary Behaviors compared with higher-income countries, yet worse
grades for supports from Family and Peers, Community and the Built Environment, and Government Strategies and Investments.
Average grades for all indicators combined were highest (best) in Denmark, Slovenia, and the Netherlands. Many surveillance
and research gaps were apparent, especially for the Active Play and Family and Peers indicators. International cooperation andcross-fertilization is encouraged to address existing challenges, understand underlying determinants, conceive innovative solutions, and mitigate the global childhood inactivity crisis. The paradox of higher physical activity and lower sedentary behavior
in countries reporting poorer infrastructure, and lower physical activity and higher sedentary behavior in countries reporting
better infrastructure, suggests that autonomy to play, travel, or chore requirements and/or fewer attractive sedentary pursuits,rather than infrastructure and structured activities, may facilitate higher levels of physical activity.
Keywords: international, play, policy, sedentary behavior, sport, active transportation
Recent systematic reviews confirm the extensive health benefitsof regular physical activity for school-aged children and youth,1 as
well as the harmful effects of excessive or uninterrupted sedentary
behavior, especially screen time.2,3 Recent reports reinforce global

public health concerns related to physical inactivity4–8 resulting incalls for more comprehensive, coordinated, and sustained efforts.4,5,9
Yet global efforts to increase physical activity and decrease sedentary behaviors have been underway for years, and progress has

Tremblay and Barnes are with the Healthy Active Living and Obesity Research Group, Children’s Hospital of Eastern Ontario Research Institute,
Ottawa, Ontario, Canada. González is with the School of Medicine, Universidad de los Andes, Bogotá, Colombia. Katzmarzyk is with the Pennington
Biomedical Research Center, Baton Rouge, LA, USA. Onywera is with the Dept of Recreation Management and Exercise Science, Kenyatta University, Nairobi, Kenya. Reilly is with the Physical Activity for Health Group, School of Psychological Sciences and Health, University of Strathclyde,
Glasgow, Scotland. Tomkinson is with the Dept of Kinesiology and Public Health Education, University of North Dakota, Grand Forks, ND, USA; andthe Alliance for Research in Exercise, Nutrition, and Activity, School of Health Sciences & Sansom Institute for Health Research, University of South
Australia, Adelaide, Australia. The Global Matrix 2.0 Research Team consists of Nicolas Aguilar-Farias (Universidad de La Frontera, Chile), Kingsley
K. Akinroye (Nigerian Heart Foundation), Mohamed Ghaith Al-Kuwari (Aspetar Hospital, Qatar), Areekul Amornsriwatanakul (University of Western
Australia), Salomé Aubert (Children’s Hospital of Eastern Ontario Research Institute, Canada), Sarahjane Belton (Dublin City University, Ireland),Aleksandra Gołdys (University of Warsaw, Poland), Marianella Herrera-Cuenca (Central University of Venezuela), Justin Y. Jeon (Yonsei University,
South Korea), Jaak Jürimäe (University of Tartu, Estonia), Tarun R. Katapally (University of Regina, Canada), Estelle V. Lambert (University of CapeTown, South Africa), Lisbeth R. Larsen (University College Lillebælt, Denmark), Yang Liu (Shanghai University of Sport, China), Marie Löf (Karolinska
Institutet, Sweden), Tom Loney (United Arab Emirates University), Juan R. López y Taylor (Universidad de Guadalajara, México), Ralph Maddison(University of Auckland, New Zealand), Taru Manyanga (Children’s Hospital of Eastern Ontario Research Institute, Canada), Shawnda A. Morrison(University of Primorska, Slovenia), Jorge Mota (Universidade do Porto, Portugal), Marie H. Murphy (Ulster University, Northern Ireland), Nelson
Nardo Jr. (Universidade Estadual de Maringa, Brazil), Reginald T-A. Ocansey (Active Healthy Kids Ghana Group, Ghana), António Prista (Universidade
Pedagógica, Mozambique), Blanca Roman-Viñas (Nutrition Research Foundation, Spain), Natasha K. Schranz (University of South Australia), Jan
Seghers (KU Leuven, Belgium), Razinah Sharif (University Kebangsaan Malaysia), Martyn Standage (University of Bath, United Kingdom), Gareth
Stratton (Swansea University, Wales), Tim Takken (Wilhelmina Children’s Hospital, the Netherlands), Tuija H. Tammelin (LIKES Research Centre forPhysical Activity and Health, Finland), Chiaki Tanaka (J.F. Oberlin University, Japan), Yan Tang (Shanghai University of Sport, China), and Stephen H.
Wong (The Chinese University of Hong Kong, China). Tremblay (mtremblay@cheo.on.ca) is corresponding author.
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S344  Tremblay et alremained elusive.10 For example, trends over the past 12 years fromthe Canadian Report Card on Physical Activity for Children andYouth show a general improvement in structures and supports forphysical activity, yet no commensurate improvement in physicalactivity behaviors.11 The general lack of progress may be related
to insufficient effort or investment; lack of or poorly implemented
policies, programs, and practices; an inadequate period of sustained
effort; and/or there may be a mismatch between strategies andrequirements for systemic behavioral change.
The development and release of Report Cards on physicalactivity for children and youth have been used in many countries foradvocacy and social mobilization to increase young people’s activity
by influencing perceptions, priorities, policies, and practices.12–14 In
2014, 15 countries produced and released Report Cards following aharmonized process, resulting in a Global Matrix of Grades.15 Thiscross-country comparison model produced provocative findings
showing that lower levels of structure, strategies, and investments
to promote physical activity for children and youth were actuallyrelated to higher levels of overall physical activity, which challenges
the conventional thinking “if you build it they will come.”15 This
paradoxical finding suggests a “one size fits all” approach, or one
informed only by evidence from high-income countries (HIC), may
need to be challenged or reconsidered.
The relationship between household income and child physical activity shows considerable between-country variation with apositive correlation observed in HIC and a negative correlation
generally observed in lower-income countries (LIC).7,15 Similarinteractions have been observed with childhood obesity levels16 andphysical activity levels in adults.17 These findings are consistent withobservations of the epidemiological, nutrition, and physical activity transitions.18–20 Furthermore, country-level factors, such as per
capita income, income inequality, and Human Development Index(HDI, http://hdr.undp.org/en/content/human-development-indexhdi) have been shown to be related to levels of childhood physicalactivity in different ways in different countries.7,21,22
With escalating interest in global solutions to current childhood
inactivity and obesity levels,4,6,10 it is responsible and pragmatic toreflect on the universality of proposed solutions and shared experiences to such pandemics. Given the lack of progress resulting frompurported solutions,10 a revisiting of such approaches, with evidence
across multiple cultures, countries, and geographies, is warranted.
The Global Matrix of Grades cited previously15 was a pilot effort
in this regard; however, it was recognized that this initial effort waslimited by the relatively small number of participating countries.
Building on the success of the Global Matrix 1.0 in 2014,15
the lead investigators from each country committed to repeating
and further developing the Global Matrix initiative.16 Accordingly,
the Global Matrix 2.0 project was initiated.23 The purposes of thisarticle are to describe the Global Matrix 2.0 project, consolidate
findings from participating countries, analyze global variations,discuss areas in which countries are leading and lagging and explore
why, and provide lessons learned from the project in the form ofrecommendations for improving the grades in all countries.

Methods
In July of 2014 the Active Healthy Kids Global Alliance distributed
an open call through established networks for interested countries toparticipate in the Global Matrix 2.0 project. Countries were required
to register their interest by the deadline of October 2015 and pay amodest participation fee (US $500) to cover costs associated withthe project. Forty countries from 6 continents responded and 38 fully
participated in the Global Matrix 2.0. Each participating country
was assigned a mentor who had participated in the Global Matrix
1.0 to guide them, ensure adherence to the harmonized processes,12and make sure they stayed on schedule.
Similar to the Global Matrix 1.0,15 all countries gathered thebest and most recent available evidence, or in some cases collected
data prospectively, and reported on 9 common indicators (Behaviors: Overall Physical Activity, Organized Sport Participation,
Active Play, Active Transportation, Sedentary Behavior; Sourcesof influence: Family and Peers, School, Community and the Built
Environment, and Government Strategies and Investments). Writing
groups employed a rigorous and transparent process for informationand data gathering, to synthesize findings and reach consensus, andfollowed a harmonized Report Card development process. Eachcountry engaged a diverse set of national experts from multiple
sectors related to physical activity and adhered to a standardized
grading framework. Full details of the Report Card development
process have been previously described.12,13,15 The Report Card was
designed as a knowledge synthesis, translation, and mobilization
instrument serving as an advocacy mechanism to drive social action
by stimulating debate, motivating policy, practice, and action, andinspiring change.12,13,15 Consequently, some countries added otherindicators to their Report Cards (eg, obesity, physical fitness, movement skills, nongovernment strategies and investments) beyond the
9 common indicators (also used in Global Matrix 1.0). In 2 cases,
common indicators were not graded (Qatar, Active Transportation;
Scotland, School). Details of the process, data availability, andinvolvement of experts in each country are described in this supplemental issue of the Journal of Physical Activity and Health.24–61
Central to the process in each country was the gathering of the best
available evidence, interpretation by the expert committee formed,
and transparent reporting.
The grading framework and benchmarks used are provided inTables 1 and 2. While the quality and quantity of data and evidence
available in each country varied substantially, countries were advised
to consider and synthesize the best available evidence for eachindicator. This is the same process employed for the Global Matrix
1.0. The expert committee, comprised of different stakeholders, ineach country discussed the total evidence base, added their expert
opinion, and reached consensus on the grade assigned for eachindicator. The rationale for each assigned grade is provided in therespective country articles.24–61 Despite variation in country data
sources it is believed that the grades across all indicators provide
a basis for comparison, and are informative of global variation inthese indicators related to the physical activity of children and youth.
Each country packaged their findings in a short-form highlight
Report Card and/or long-form Report Card that provided substantiation of the grades and full data source information, as well as alist of expert committee members. Countries developed a “coverstory” based on important themes in their Report Card findings, tohelp promote the Report Card, its findings, and recommendations.
Illustrations of the cover story from each country are provided in
the country-specific articles.24–61 Complete copies of each country’s
Report Cards are available at www.activehealthykids.org. The
Global Matrix 2.0 findings and each country’s Report Card were
presented at the International Congress on Physical Activity andPublic Health in Bangkok, Thailand in November 2016.
In addition to descriptive presentation and narrative interpretation of results within and between countries, quantitative analyses
were also performed. A correlational analysis was performed todetermine the extent to which Report Card grades were related

JPAH Vol. 13, Suppl. 2, 2016

Table 1

Grading Framework for the Report Card

GradeInterpretationA

We are succeeding with a large majority of children and youth (≥ 80%).

B

We are succeeding with well over half of children and youth (60–79%).

C

We are succeeding with about half of children and youth (40–59%).

D

We are succeeding with less than half but some children and youth (20–39%).

F

We are succeeding with very few children and youth (< 20%).

INC

Incomplete—inadequate information to assign a grade.

Note. “+” and “-” signs are added to the grades in some circumstances to indicate the high or low end of the grade continuum respectively and/or to indicate the presence(“-”) or absence (“+”) of significant gender, geographic, ethnic, or socioeconomic disparities.

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Table 2

Benchmarks Used to Guide the Grade Assignment for Each Indicator

Indicator

Benchmark

Overall Physical Activity% of children and youth who meet physical activity guidelines

Organized Sport Participation% of children and youth who participate in organized sport and/or physical activity programs

Active Play% of children and youth who engage in unstructured/unorganized active play for several hours a day

Active Transportation% of children and youth who use active transportation to get to and from places (school, park, mall, friend’s place)

Sedentary Behavior% of children and youth who meet sedentary behavior or screen-time guidelines

Family and Peers% of parents who facilitate physical activity and sport opportunities for their children (eg, volunteering, coaching,driving, paying for membership fees and equipment)% of parents who meet the physical activity guidelines for adults% of parents who are physically active with their kids
% of children and youth with friends and peers who encourage and support them to be physically active% of children and youth who encourage and support their friends and peers to be physically active

School% of schools with active school policies (eg, Daily Physical Activity, recess, “everyone plays” approach, bikeracks at school, traffic calming on school property, outdoor time)% of schools where the majority (≥ 80%) of students are taught by a Physical Education specialist% of schools where the majority (≥ 80%) of students are offered at least 150 minutes of Physical Education per
week% of schools that offer physical activity opportunities (excluding Physical Education) to the majority (≥ 80%) ofstudents% of parents with children and youth who have access to physical activity opportunities at school in addition to
Physical Education% of schools with students who have regular access to facilities and equipment that support physical activity (eg,gymnasium, outdoor playgrounds, sporting fields, equipment in good condition)

Community and the Built
Environment% of children or parents who perceive their community/municipality is doing a good job at promoting physicalactivity (eg, variety, location, cost, quality)% of communities/municipalities that report they have policies promoting physical activity% of communities/municipalities that report infrastructure (eg, sidewalks, trails, paths, bike lanes) specifically
geared toward promoting physical activity% of children or parents with facilities, programs, parks and playgrounds available to them in their community% of children or parents living in a safe neighborhood where they can be physically active% of children or parents reporting well-maintained facilities, parks/playgrounds in their community that are safe
% of children and youth who report being outdoors for several hours a day

Government Strategies
and Investments

Evidence of leadership and commitment in providing physical activity opportunities for all children and youth
Allocated funds and resources for the implementation of physical activity promotion strategies and initiatives for
all children and youth
Demonstrated progress through the key stages of public policy making (ie, policy agenda, policy formation, policy
implementation, policy evaluation and decisions about the future)

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S346  Tremblay et al

to several global descriptors and demographic indices, including:the HDI (2014 data calculated from life expectancy at birth, meanand expected years of schooling, gross national income per capita;
greater scores represent greater human development),62 the Gini
Index (1995–2013 data calculated from distribution of income;greater scores represent greater income inequality),63 the Gender
Inequality Index (2014 data calculated from maternal mortality ratio
and adolescent birth rates, proportion of parliamentary seats occupied by females and proportion of adult females and males aged 25
years and older with at least some secondary education, labor force
participation rate of female and male populations aged 15 years andolder; greater scores represent greater gender inequality),64,65 the
Global Food Security Index (2016 data calculated from measuresof affordability, availability, quality, and safety; greater scores
represent greater food security),66 summer Olympic medal count(indicator of sporting success; 1896–2016 data),67 and distancefrom the Equator (broad indicator of climate/weather/temperature/seasonal variations; calculated from the geographic center of eachcountry68 using a latitude/longitude distance calculator).69 England, Scotland, and Wales were grouped together for this analysis
because these indices had data for Great Britain only and not theindividual countries.
All Report Card letter grades were converted to numeric ordinalscores (A = 5, B = 4, C = 3, D = 2, F = 1). For simplicity, signed
letter grades were treated as nonsigned letter grades (eg, A+, A-, A= 5) for the conversion. The arithmetic mean (overall Report Card
grade) was calculated for each country by summing the ordinalscores for all 9 common indicators and dividing by the number ofordinal scores. The behavior grade and the sources of influence
grade were calculated similar to the overall Report Card grade butwith the ordinal scores limited to the Behaviors (Overall Physical
Activity, Organized Sport Participation, Active Play, Active Transportation, Sedentary Behavior) and Sources of Influence combinedwith Government Strategies and Investments common indicators,
respectively. Due to the ordinal nature of the grade data, Spearman’srank correlation coefficients were calculated. Statistical significancetests were also performed on these coefficients and α was adjusted
for multiple comparisons (0.05/18 = 0.003). All correlation andsignificance tests were performed using R version 3.3.0 (Vienna:
The R Foundation for Statistical Computing Platform).

Results
Figure 1 depicts the global dispersion of the countries participatingin the Global Matrix 2.0. The 38 participating countries represent
approximately 20% of the countries in the world (including all
inhabited continents), 40% of the world’s land mass, 60% of theworld’s population, and >150% increase in participating countries
compared with the Global Matrix 1.0.23
The consolidated findings are summarized in the form of a
Global Matrix, which demonstrates substantial variation in grades
both within and across countries (Table 3). The Global Matrix 2.0
results are presented in different formats to facilitate interpretation.
Table 3 presents the Global Matrix 2.0 with grades organized bycountry, listed alphabetically within continents. Table 4 presents thecountries organized hierarchically by grade for each indicator. Thesetables show a large spread in grades across countries (Overall Physical Activity F to A-; Organized Sport Participation F to A; Active
Play F to B; Active Transportation F to A; Sedentary Behaviors F to

Figure 1 — Global map indicating the location of countries participating in the Global Matrix 2.0 (in black).
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JPAH Vol. 13, Suppl. 2, 2016

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C

Average

D
F
DD-

Qatar

South Korea

ThailandBC

Average

D
B

D
D
D
F

Netherlands

PolandPortugal

Scotland

INC

B

C-/C+

C

C

D

D

F

EstoniaD

D-

EnglandA

FinlandD+

Denmark

C-

C/B

C+

B

C

INC

C

C-

D

INC

C

INC

C-

F

C

B

C

INC

F

C

C

Organized
Sport
Participation

IrelandF+

Belgium

EuropeD-

New ZealandD

Australia

Oceania

Average

D-/F-

INC

Japan

Malaysia

United Arab Emirates

DC-

Hong Kong

India

F

China

Asia

C

C

NigeriaC+

C

Mozambique

Zimbabwe

C

South Africa

D

Ghana

Overall Physical
Activity Levels

INC

D

INC

B

INC

C

INC

INC

INC

C+

B

B-

INC

F/D

INC

F

INC

INC

INC

INC

INC

INC

D-

C

D+

INC

C

D

B

B

Active
Play

C

C

C

A

D

B

INC

C-

B

C-

C

C

C-

C

D-/F-

B

C+

-

D

B

C

B

C-

B

A-

C

B

C

B

C

ActiveTransportation

F

D

D

C

C-

D

F

INC

INC

D-

D/C

C

D-

D

C-

D-

F

D

D

C

C

C

F

D

B

F

F

INC

B

D

Sedentary
Behaviors

Global Matrix 2.0 With Countries Presented Alphabetically Within Continents

Kenya

AfricaCountry

Table 3

D-

C

C

B

INC

C

C

INC

INC

INC

C

C

C+

C

C-

B

INC

D

INC

D

INC

D

B

D

INC

C-

INC

INC

D

F

Family andPeers

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-

B

B

C

D

B

C

B+

B

B-

C/B

C+

B-

C

D

C

D

INC

B

B

INC

C

B+

D

D

D

C-

D

C

D

School

B

D

C

A

B+

B

B

B

B+

INC

B/A

B

A-

C

INC

C

INC

INC

INC

D

INC

B

D+

D

F

C-

INC

F

D

F

Communityand Built
Environment

B

C

C

INC

INC

B

C

INC

A-

C+

C

B-

D

C

B+

C

C

B

B

B

D

INC

D

C

D

B

B

F

C

D

Government
Strategies andInvestments(continued)

C

C

C

B

C

C

C

C

B

C

C

C

C

C

C

C

D

D

C

C

C

C

D

C

C

C

C

D

C

D

AverageAcross All
Indicators

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JPAH Vol. 13, Suppl. 2, 2016

D
D-

Sweden

Wales

C
DD

MexicoUnited States

AverageC

D

Average

INC
C

-

INC

INC

INC

INC

D

INC

D-

D+

C

C

INC

C+

D

Active
Play

C

C

INC

D

C-

C+

D

F

C

D

C

C

C+

C

C

ActiveTransportation

D

D

D/F

D

D

D+

D

D-

D

F

D

D-

C

D

B+

Sedentary
Behaviors

C

C/D

INC

INC

D

C+

C

INC

INC

C+

C

D+

INC

INC

INC

Family and
Peers

C

D

INC

D

D

INC

C

D+

D-

B

B

B

C+

C

A

School

C

C

INC

C

C

INC

B

B-

D

A-

B

C

B

INC

INC

Communityand Built
Environment

C

C

D

B/B

C

D

C/B

INC

C

B-

B

B-

B

INC

B+

Government
Strategies andInvestments

C

D/C

D

C

D

C

D

D

D

C

C

C

C

C

B

AverageAcross All
Indicators

Note. The grade for each indicator is based on the percentage of children and youth meeting a defined benchmark: A is 81% to 100%; B is 61% to 80%; C is 41% to 60%, D is 21% to 40%; F is 0% to 20%. No grade was
assigned when the data were considered to be incomplete (INC).

Overall average

D/C

D
D

Venezuela

C

D

F
D

Colombia

INC

C

C-

D

B

C

C

B+

B

B-

Organized
Sport
Participation

Chile

C-

BrazilSouth America

D-

CanadaNorth America

D

D-

Spain

AverageA-

Overall Physical
Activity Levels

Slovenia

Country

Table 3 (continued)

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New ZealandZimbabwe

C+

BrazilCanadaSwedenSpain

Australia

BrazilSouth Korea

Belgium

Portugal

ThailandSlovenia

PolandNigeria

Zimbabwe

SwedenNew Zealand

Belgium

Australia

Wales

Malaysia

Kenya

Japan

FinlandDenmark

United States

SwedenScotland

New ZealandHong Kong

Finland

Estonia

England

Ireland

CanadaDenmark

China

CanadaAustralia

Netherlands

Community & Built
Environment

England

Slovenia

SchoolSpain

Thailand

Netherlands

China

Family & Peers

Japan

Zimbabwe

Kenya

Slovenia

Sedentary
Behaviors

Portugal

New ZealandFinlandHong Kong

Kenya
Netherlands

CanadaNetherlands

Zimbabwe

Netherlands

Denmark

Active Play

ActiveTransportation

Ghana

Australia

SwedenDenmark

Organized
Sport
Participation

New Zealand

Slovenia

Overall Physical
Activity

Global Matrix 2.0 Presented in Rank Order by Grade

B-

B

B+

A-

A

A+

Grade

Table 4

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BelgiumWales

New Zealand

CanadaSwedenSouth Africa

Scotland

Qatar

Nigeria

Malaysia

Japan

Finland

Colombia

United ArabEmirates

Slovenia

Denmark

Government
Strategies &Investments

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New Zealand
PolandPortugal
ScotlandSlovenia
South Africa

Ireland
Japan
Kenya

South Africa
Thailand
Wales

South Africa

Qatar
Spain

Portugal

SwedenVenezuela

Portugal

Malaysia

Ghana

Finland

Colombia

PolandQatar

Ireland

Malaysia

Ireland

Colombia

PolandPolandHong Kong

PortugalSlovenia

Chile

Netherlands

MexicoGhana

CanadaMexicoEnglandFinland

Zimbabwe
Mozambique

Qatar

Kenya

Japan

Hong Kong

Chile

Wales

United ArabEmirates

United ArabEmirates

BrazilSouth Africa

Portugal

PolandNew ZealandFinland

Estonia

Family & Peers

IrelandSwedenNew Zealand

Netherlands

Japan

India

Hong Kong

Sedentary
Behaviors

Malaysia

Chile

Colombia

D

China

United States

Denmark

Chile

South Korea
England

BelgiumHong Kong

India

Australia

Belgium

Wales

Spain

Mozambique

BrazilCanadaIndia
Mexico

Ghana

Wales

Nigeria

Nigeria

Estonia
Finland

MexicoGhana

ActiveTransportation

MozambiqueFinland

Active Play

Colombia

Kenya

D+

C-

C

Grade

Organized
Sport
Participation

Overall Physical
Activity

Table 4 (continued)

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SchoolZimbabwe

United ArabEmiratesSouth Korea

South Africa

Mozambique

Ireland

Ghana

Chile, Colombia

United States

Nigeria

Thailand

Spain

Netherlands

Kenya

Hong Kong

Estonia

PortugalMexico

Kenya

Japan

China

South Africa

Wales

Thailand

PolandColombia

Chile

Community & Built
Environment(continued)

Zimbabwe

Venezuela

India

Ghana

China

BrazilAustralia

ThailandSouth Korea

Portugal

PolandMexicoKenya

Estonia

Chile

Government
Strategies &Investments

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F

D-

Grade

Thailand

United ArabEmiratesSouth Africa
South Korea

Scotland

Scotland

Qatar

United ArabEmirates

Nigeria

China

Estonia

United States
Estonia

Mozambique

China

Chile

Belgium

Wales
CanadaWales

Thailand

United States

Venezuela

South Korea

United States

Spain

Belgium

Australia

Sedentary
Behaviors

Thailand

China

ActiveTransportation

England

MexicoCanadaActive Play
China

Organized
Sport
Participation

Australia

Overall Physical
Activity

Table 4 (continued)

Ghana

ScotlandFamily & Peers

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SchoolMexicoZimbabwe

Mozambique

Ghana

Community & Built
Environment(continued)

Mozambique

Government
Strategies &Investments

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Qatar

Chile
Colombia
Denmark
England
Estonia

Nigeria
Scotland

United ArabEmirates

Venezuela

Nigeria
Slovenia
South Korea
Spain
SwedenUnited States
Venezuela
Zimbabwe

IrelandJapan
Malaysia
PolandQatar
ScotlandSouth Africa
South Korea

Venezuela

Scotland

Qatar

India

BrazilSchoolVenezuela

United Arab Emirates

Spain

South Korea

Slovenia

Qatar

Nigeria

Malaysia

India

BrazilBelgium

Community & Built
Environment

United States

Spain

Netherlands

IrelandHong Kong

EnglandGovernment
Strategies &Investments

Note. The grade for each indicator is based on the percentage of children and youth meeting a defined benchmark: A is 81% to 100%; B is 61% to 80%; C is 41% to 60%, D is 21% to 40%; F is 0% to 20%. No grade was
assigned when the data were considered to be incomplete (INC).

Venezuela

United States

United ArabEmirates

SwedenMozambique

India

Malaysia

Ireland

India

EnglandDenmark

Colombia

Belgium

Family & Peers

MexicoMozambique

EnglandDenmark

Sedentary
Behaviors

Hong Kong

Venezuela

BrazilIndia

Active Play

Malaysia

INC

Estonia

Brazil

Japan

Grade

ActiveTransportation

Australia

Organized
Sport
Participation

Overall Physical
Activity

Table 4 (continued)

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Global Matrix 2.0 Report Card Grades   S353

B+; Family and Peers F to B; School D- to A; Community and the
Built Environment F to A; Government Strategies and Investments
F to A-) and that most countries are having both successes and challenges. Several countries had inadequate information to assign a
grade (INC), most notably for Active Play (21 countries) and Family
and Peers (17 countries). Venezuela was the most evidence-limited
country, reporting INC grades for 6 of 9 indicators,59 although thedefinition of insufficient evidence to record a grade of INC varied
across countries.
The findings showed that on average the grades were low (D)for Overall Physical Activity, Active Play, and Sedentary Behavior(Table 3). The grades for sources of influence were generally higher
than the behavior grades. The Community and the Built Environment indicator had the highest overall grade, though 12 countries
reported INC. Overall behavior grades (Overall Physical Activity,
Organized Sport Participation, Active Play, Active Transportation,
Sedentary Behavior) were lower in participating Asian, North
American, and South American countries compared with countries
from the other continents. Average grades across all indicators werehighest in Denmark,31 Slovenia,51 and the Netherlands.44 Sixteen
countries reported at least 1 F grade and 30 countries reported atleast 1 D grade. In contrast, only 6 countries reported at least 1 A
grade.
Results of the correlational analysis of grades according toseveral global descriptors and demographic indices are presented
in Table 5. No significant relationships were observed with Overall
Behavior grades. For the Sources of Influence grades, strong positive
relationships were observed with HDI62 and Global Food Security
Index,66 while strong negative relationships were observed with theGini Index63 and Gender Inequality Index.64,65 A significant positive
relationship with distance from the equator68,69 was also observed.
No significant relationship between grades and summer Olympic
medal count67 was observed, although it did show a rather strong
positive correlation with Sources of Influence grades.
The Community and the Built Environment indicator received
high grades in HIC and lower grades in LIC. There was a patternof higher Overall Physical Activity in countries reporting poorer
infrastructure (ie, grades on Sources of Influence), and lower Over-

Table 5

all Physical Activity in countries reporting better infrastructure.
Similarly, some countries have relatively high grades for the policy
environment but relatively low grades for the health behavior indicators the policies are targeting (for countries with A or B grades for
Government Strategies and Investments Spearman’s rho (Overall
Physical Activity ~ Government grade) = –0.17, P = .58).

Discussion
The findings from this paper represent the richest and most diverse
comparison of physical activity–related indicators for children andyouth assembled to date, involving 38 countries from 6 continents.
The wide range of grades observed, from A to F for most indicators,
demonstrates that success is possible, at least for some countries.
This reality provides for creative and innovative learning opportunities across countries and reinforces, while extending, the learning
gained from the Global Matrix 1.0.15 Because of the substantial
variation in grades, the global matrix provides a useful framework
for consolidating and assessing the best available evidence aimed
at understanding differences between and within countries. From
Tables 3 and 4 it is clear that no one country is leading or lagging
in all indicators but, rather, each country has a blend of successes
and challenges.24–61 Not surprisingly, the wide distribution of grades
results in global average grades for all indicators being D or C.
The evidence contained in the Global Matrix 2.0 shows that thechallenge of enhancing physical activity behaviors and opportunities for children and youth around the world remains unresolved,
and tackling this challenge together may provide unique insights,
motivation, and synergy that could not be achieved in isolation.
The overall findings from the Global Matrix 2.0 showed thaton average the grades were low for Overall Physical Activity, Active
Play, and Sedentary Behavior, reinforcing the global concern aboutchildhood physical activity levels.15,70 Similar to the Global Matrix
1.0, the grades for sources of influence were generally higher
than the behaviors they aim to influence, suggesting that “making
the healthy choice the easy choice” through environmental andpolicy supports has a substantial latent period before the influence

Correlation Matrix (Spearman’s rho) of Average Country Report Card Grades by Global Descriptors
Health and Education
IncomeDistribution

Nutrition

GenderInequality
Index64

Gini Index63

Global Food
Security Index66

Summer Olympic
Medal Count67

0.935 (Australia),

0.016 (Slovenia),

25.6 (Slovenia),

0.416 (Mozambique)0.591 (Mozambique)63.4 (South
Africa)86.6 (UnitedStates),

2,520 (UnitedStates),29.4 (Mozambique)2 (Mozambique)

Overall Report Card
Gradea0.32–0.55*

–0.44

0.30

0.17

0.29

Behavior Gradeb

0.12

–0.26

–0.23

0.19

0.04

0.07

Sources of Influence
Gradec0.60*–0.77*–0.55*

0.58*

0.45

0.48*

Rank (Highest,
Lowest)IncomeEmpowerment
and Labor

Human
Development
Index62

Other
Distance fromthe Equator(km)682 (Kenya),
7,219 (Finland)* P < .003 (note: due to multiple comparisons, α = .003 [0.05/18]).
a Average of all 9 indicators for a country; b Average of Overall Physical Activity, Organized Sport Participation, Active Play, Active Transportation, Sedentary Behavior
indicator grades; c Average of Family and Peers, School, Community and the Built Environment, and Government Strategies and Investments indicator grades.
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S354  Tremblay et al

is translated into behavior change, or it is not as strong a behavior
driver as generally believed.
While there are successes and challenges across countries, thegrades for Denmark,31 the Netherlands,44 and Slovenia51 generally
showed greater success. In these countries there is both a welldeveloped infrastructure and policy support network for healthy
active living as well as individual commitment to habitual physical activity embedded in all aspects of life (eg, recreation, play,transportation, school).
The Danish Report Card illustrates that despite a high priority at a governmental level to facilitate physical activity and many
strategies to promote physical activity, a large proportion of Danish
children seem not to comply with the recommendation for physicalactivity. This highlights that even if a country performs very well at
the strategic and political level, the impact at the individual level is
not assured. There is a gap between the governmental level and theindividual level that needs to be bridged to increase physical activity
and decrease sedentary behavior in children. So despite the relatively high average grade across all indicators, the grade that is mostcoveted, Overall Physical Activity, remains below desired levels.
In the Netherlands, every city or village has an extensive layoutof cycle paths and routes. In many urban areas separate cycle paths
are not uncommon. Further, there is a high percentage of bike ownership: 84% of the Dutch inhabitants from age 4 years and older own
a bicycle.44 Furthermore, many municipalities are promoting bikeuse and are banning cars from the inner cities. However, despiterobust policies and infrastructure, these supports are not sufficient
to score highly on Overall Physical Activity (based on the available
measures).44
In Slovenia, physical activity in children is closely monitored
within the school system. Every April, the majority of Slovenian
children and youth (aged 6 to 19 y) are included in nation-wide,school-based physical fitness measurements. This initiative is called
SLOfit—the Sport Educational Chart program. SLOfit is obligatory
for all Slovenian primary and secondary schools across the country.
For more than 30 years, this system has given teachers, researchers, and policy-makers access to high-quality, standardized dataon physical fitness, which in turn allows for relatively responsive
evidence-based policy adjustments when needed. For example,
based on more recent evidence of declining physical fitness fromthe SLOfit database, Slovenia introduced a health-oriented physicalactivity intervention program called Healthy Lifestyle in the school
year 2010/2011, offering children 2 optional, additional hours ofphysical activity per week. Healthy Lifestyle is considered part ofa school’s regular extracurricular health-oriented physical activity
program. This project currently includes more than 30% of theentire primary-school population. Before this initiative, Slovenian
children had been experiencing negative trends in motor and physical fitness for over 2 decades, but since 2011, physical fitness in
6- to 14-year-olds has been steadily improving.71
While Denmark, the Netherlands, and Slovenia are each generally overcoming challenges more successfully than other countries,
the key to their success is not uniform, suggesting multiple strategies can, and perhaps should, be pursued in an effort to improve
Report Card grades.

Successes and Challenges Based on Indicator
GradesFindings for each of the 9 common indicators are discussed further
in subsections below.

Overall Physical Activity. Slovenia reported the highest grade(A-)51 for Overall Physical Activity while 20 countries reportedlow (D) and 7 countries failing (F) grades, suggesting there is
widespread evidence of a childhood physical inactivity crisis. One
country (Japan) assigned an INC grade.39 The high grade achievedin Slovenia is attributed to highly developed and apparently effective
structured physical activity opportunities through school physicaleducation and structured sport opportunities both in school and in thecommunity.51 The low grades in most countries are consistent withearlier reports.7,15,70 Grades were generally higher in low-middle
income countries (LMIC; Brazil,26 India,37 Kenya,40 Mexico,42
Mozambique,43 Nigeria,46 South Africa,52 Zimbabwe61), but thisrelationship was not uniform as Slovenia51 and New Zealand45 also
reported high grades and no significant correlation between HDI
and overall behavior grades was observed (Table 5).
Caution needs to be employed when interpreting direct comparisons among countries because of significant variation in sampling and measurement procedures. Despite these well-described
limitations,72,73 some insights can be drawn from the variations
observed in global physical activity levels. The findings seen in the
Global Matrix 2.0 were also seen with the International Children’s
Accelerometry Database, which showed that North American
children were less active than those in Northern Europe.74 The
lower overall behavior grades reported by Asian, North American,
and South American countries compared with countries from theother continents is consistent with a recent report of variations in
the cardiorespiratory fitness levels of children and youth across 50
countries.75 The best performing countries on the 20-m shuttle run
were from Africa and Northern Europe while countries from SouthAmerica were consistently among the worst performing countries.75
The Report Card overall grades showed negative relationships
with Gini Index (country-specific income inequality)63 and Gender
Inequality Index,64,65 indicating that greater inequality is associatedwith lower grades. A similar pattern was observed with the 20-m
shuttle run performances reported by Lang et al.75 The patternof variability observed in the Overall Physical Activity grades isbroadly consistent with the theory of an epidemiological18 andphysical activity transition19 suggesting that countries with a higher
HDI generally show lower physical activity behaviors commensurate with contemporary lifestyles influenced by automation andconvenience. A systematic review of data from Sub-Saharan African
school-aged children by Muthuri et al76 found inverse associations
between physical activity and fitness, and urban living and higher
socioeconomic status, suggesting that economic development may
be related to reduced healthy active lifestyles and fitness. Nevertheless, the success achieved in Slovenia suggests that behavioral
changes associated with such transitions are not inevitable.
Organized Sport Participation. The average grade for OrganizedSport Participation was a C, the highest average grade for any ofthe behavior indicators. Denmark had the highest grade (A)31 and9 countries had grades of B or higher. Only 7 countries reported
grades of D or F, and 7 countries reported INC grades. Nine out of
the top 10 grades for this indicator were from HIC while the only
2 F grades were from LMIC. The average grade of C indicatesthat approximately half of children and youth report participatingin sport.
Grades for Organized Sport Participation seem positively
related to grades on the School and Community and the Built
Environment indicators [eg, countries with good grades for Organized Sport Participation also reported relatively good grades for
School and Community and the Built Environment (eg, Australia,24

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Canada,27 Denmark,31 the Netherlands,44 Sweden55), whereas
countries with low grades for Organized Sport Participation often
reported low grades for School and Community and the Built Environment (eg, Chile,28 Mexico,42 Mozambique43)]. This relationshipwas significant (Spearman’s rho for Organized Sport Participation
grade ~ School + Community and Environment grades = 0.42,
P = .02) and is not surprising considering that organized sport
opportunities require space, facilities, equipment, programs, safety
precautions, and supervision. While most countries assigned grades
for Organized Sport Participation, details of the quality, frequency,
duration, intensity, context (eg, physical education, extracurricular,
community sport), and seasonality of participation varied significantly and/or were generally lacking.
Active Play. No countries reported a grade of A for Active Play;the highest grade was B (Ghana,35 Kenya,40 the Netherlands44).
Eight countries reported low grades (D or F). Notably, 21 countries
reported INC grades, identifying the need for greater clarity on
the definition and benchmarks, and subsequent surveillance of
this important indicator. One problem often cited was the lack ofvalid and reliable measurement methodologies and instruments toaccurately quantify Active Play; consensus is required on a definition
for Active Play and how to measure it. No clear pattern of country
characteristics associated with high or low grades emerged.
The 2015 ParticipACTION Report Card from Canada focusedon active outdoor play77 and included a Position Statement on
Active Outdoor Play developed by several organizations in Canada
and informed by 2 systematic reviews.78–80 The benefits of active
outdoor play (defined as freely chosen, spontaneous, and selfdirected physical activity involving an element of fun done in theoutdoors) are diverse, substantial, and substantiated.78 Indeed, thetrend—especially in HIC—is toward greater indoor time, which
the Position Statement argues is in fact a greater risk than theoutdoors, because of the greater likelihood of low physical activity, high sedentary behavior, relatively higher risk of contact withcyber-predators, greater incidental eating, and exposure to toxins
in indoor air, among other factors.78 A recent report demonstrated
that each additional hour spent outdoors is associated with 7 additional minutes of moderate- to vigorous-intensity physical activity(MVPA) and 13 less minutes of sedentary time, as well as lower
odds of negative psychosocial outcomes, among 7- to 14-year-old
Canadian children.81 Similarly, a study on 11-year-old children
using objective monitoring in the United Kingdom reported thattime spent outdoors resulted in nearly 3 times more physical activity
than time spent indoors.82 Active play, especially in the outdoors,
seems to be increasingly replaced by use of electronic screens forentertainment, used almost always indoors.77,78 This trend makes
the careful monitoring and surveillance of active play important for
guiding future strategies and interventions.
Much active play is likely light-intensity physical activity
and may not be captured in the evaluation of the Overall Physical
Activity grade. The importance of light-intensity physical activity,
especially in the form of active play, is largely unknown and likely
varies significantly among countries, between sexes, across ages,
and in urban and rural areas. An emerging interest in the contribution of light-intensity physical activity, such as is typically obtained
through Active Play, is evident in the recommendations from theWorld Health Organization Commission on Ending Childhood
Obesity83 and the new Canadian 24-Hour Movement Guidelines
for Children and Youth.84 With play identified as a fundamental
right of children,85,86 and with high levels of sitting87,88 and indoor
time,81 the opportunities to promote physical activity through anincrease in active play, especially outdoors, are plentiful and should
be a high priority.15,78
Active Transportation. Active Transportation grades showed awide distribution with the Netherlands reporting an A,44 Zimbabwe
an A-,61 7 countries a B, 19 countries a C, 5 countries a D, 2 countries(United Arab Emirates,56 United States57) an F, and 3 countries
an INC. While active transportation may be a necessity for somechildren in countries such as Zimbabwe,61 Nigeria,46 and Kenya,40 inother countries with high grades it represents a choice that may be
driven more by supportive policies and/or traditional cultural norms(eg, Denmark,31 Finland,34 the Netherlands44). Multicountry studies
have shown similar proportions of active transportation involvementin significantly differing contexts.89,90 To understand these patterns a“need-based framework” has been proposed for LMIC, where active
transportation represents the only option for transportation because
motorized vehicle availability remains relatively low in comparison
with HIC. The patterns observed in HIC can be understood withina “choice-based framework” where policies and infrastructure
facilitate active transportation as an option to commute.
Interestingly, countries with high grades for this indicator comefrom very diverse climates, suggesting weather is not necessarily akey determinant. The grades for countries in Africa were on average
better than grades from countries in other continents. The grades
for North American countries were generally lower than those fromother continents.
While active transportation has been associated with increased
physical activity,91 cardiorespiratory fitness,91 and lower measures ofadiposity,90 evidence suggests that levels of active transportation are
declining.92–100 Generational declines in active transportation101,102
and independent mobility103 have also been observed. These trends
are consistent with the increased fear of the outdoors and a convenience lifestyle.78 The fact that several countries have been able toresist or counter these trends is encouraging and provides for thetransference of evidence and experiences between countries leading and lagging in this indicator. Active transportation, whether forschool, work, chores, or play varies dramatically between urban andrural settings, especially in LMIC where motorized transport is often
not available.19,101,104 It will be important to carefully monitor active
transportation behaviors in rural areas in developing countries as
motorized transport becomes increasingly available and subsistence
demands become increasingly mechanized.19 During this transitionin these needs-based circumstances, it is also important to monitor
and mitigate the unintended consequence of pedestrian injuries
associated with children actively commuting.
Sedentary Behavior. There is considerable global variation ingrades for sedentary behaviors, although the majority of countries
have very poor or failing grades. Slovenia,51 Kenya,40 and Zimbabwe61
had grades in the B range while 24 countries had grades of D or F.
All continents had an average of a D grade. These grades identify aserious and widespread problem of excess screen viewing (>2 hours
per day of recreational screen time105,106). Access to convenienceand digital technology (eg, motorized vehicles, electronic screens)
is likely facilitating sedentary behavior. Recent research comparing
17 HIC, middle-income countries (MIC), and LIC demonstrated thathousehold ownership of televisions, computers, and cars increased
as country income level increased; that ownership was positively
associated with obesity and diabetes in LMIC; and this relationshipwas partially mediated by decreased physical activity and increased
sedentary behavior.107 Temptations for sedentary behaviors are
increasing as the world becomes increasingly cyber-centric,

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S356  Tremblay et alauto-dependent, and urbanized, consistent with epidemiologicaland physical activity transitions.18,19,101 Self-report sedentary
behavior data on representative samples of children and youth from42 countries revealed that 62% and 63% of 13- and 15-year-olds,
respectively, watched ≥2 hours of television per day on weekdays.7
Despite evidence that television viewing time in some countries
may be decreasing among children, other sedentary screen timeuse (eg, computers, tablets, smartphones, electronic games) has
more than compensated for this decline.7 Many parents agree that
their children spend too much time watching television or playing
electronic games.108
The overall findings from the Global Matrix 2.0 and international surveys suggest that when sedentary behaviors are high (ie,low grades), physical activity levels are low (Spearman’s rho =
0.44, P < .01). The study of sedentary behavior, from a movement
behavior perspective, has gained significant momentum in recent
years, in recognition of the significant relationship with measuresof health and health risk.88,105–114 The ubiquity of low grades in the
Global Matrix 2.0 suggests that public health messaging aroundlimiting sedentary behavior, and screen time in particular, may be
an important area of focus and research as lifestyle transitions occur
throughout the world. Measures of screen time and related technologies are evolving rapidly and future surveillance must attempt tokeep pace with this evolution. It should be noted that the sedentary
behavior indicator in the Report Cards was informed in all countries exclusively by screen-time, or specifically television viewing
time. In the future, measurement of nonscreen sedentary behaviors(eg, time spent sitting while not in front of screens), fragmentation of sedentary time (eg, interruptions, breaks), and research on
their relationship with health outcomes are needed. At the present
time, overall sedentary behavior (ie, total or leisure-time sitting)guidelines do not exist for children and youth, making it difficult tocreate benchmarks to inform the development of a grading rubric.
Future research should be directed toward identifying dose-response
relationships between total time spent in sedentary behaviors andhealth outcomes in children and youth, that will in turn inform thedevelopment of comprehensive sedentary behavior guidelines. In
this regard, a recent meta-analysis by Liu et al3 suggests that screen
time in children and adolescents is associated with depression risk
in a nonlinear dose–response manner.
Family and Peers. China,29 the Netherlands,44 and Thailand56

had the highest grades (B) for the Family and Peers indicator,
while Ghana35 had the lowest grade (F). Similar to the Active Play
indicator, many countries (17) assigned an INC grade. Participating
experts and recent reviews115–118 support the importance of Family
and Peers as a core indicator of the physical activity of children
and youth; however, the lack of valid and reliable measurement
instruments has led to a dearth of empirical data for the establishedbenchmarks (Table 2). Countries from Africa had a lower average
grade for the Family and Peers indicator compared with the othercontinents, perhaps suggesting that physical activity was more aroutine requirement of daily living (eg, chores, active transportation,
active play) with less attentiveness or need for family and peer
support. Alternatively, a lower awareness of the importance ofhabitual physical activity may have contributed to this slightly lower
continental average. Published literature in this area is difficult tofind. A survey of parents in 25 countries with children up to 12 yearsof age in 2010 reported playing with their children an average of
14.3 hours per week in a typical week.108 Wide country variations
were noted with means ranging from 10.5 hours in Denmark to 20.0
hours in China.108 A number of confounding variables, including

family size and composition, employment logistics, urban-rural
residence, climate, and variable definitions of “play” complicate
the interpretation of these findings.
The importance of positive role modeling of parents and theirsupport of childhood physical activity is well known.119–121 A recent
cohort study reinforced the importance of parental role modelingfor both physical activity and sedentary behavior, demonstrating
significant associations between preschool children’s behaviors andtheir parents, and further observing the potentially important roleof same and different sex parental-child relationships.122 While therole of peers and parents in creating supportive environments forphysical activity is unequivocal, drawing any firm insights from the
Global Matrix 2.0 in this regard is difficult.
Grades for the School indicator ranged from A in
Slovenia51 to D- in Mexico42 with a relatively even distribution ofgrades by other countries between these extremes (Table 4). There
was a clear trend toward higher grades in HICs and lower gradesin LMICs. The high grade for Slovenia was associated with thefact that physical education is a standardized, compulsory subject
in all primary and secondary schools. Although total activity hours
can vary by grade level, from grade 6 through secondary school,
100% of physical education classes (and more than two-thirds
in primary schools) are taught by physical education specialists
with a university degree in that field. Regarding school sports
infrastructure, all primary schools (and most secondary schools)
have at least 1 sport hall fully equipped with the necessary sports
equipment and additional outdoor facilities. All schools in Slovenia
also have defined, explicit physical activity policies (eg, bike racks
at school, traffic calming on school property, outdoor time). In
general, the grades for School do not appear to be closely related to
the Overall Physical Activity grades. This observation is supportedby the average School grades by continent (Table 3) with Oceania,
Europe, and North America reporting 2 full grades higher for the
School indicator than the Overall Physical Activity indicators,
whereas in Africa the School indicator was a full grade lower thanthe Overall Physical Activity Indicator.
International comparisons of school-based physical activity
supports, opportunities, facilities, and policies are scarce. A recent
comprehensive report of 30 European countries around school-based
initiatives and strategies to promote and support physical educationand school-based physical activity highlighted important differences
across Europe123 and noted that in some countries time devoted tophysical education was <10% of total curricular time.123 To reduce
costs and/or create more time for other subjects, a trend toward a
reduction in the quality and/or quantity of physical education has
been observed in many countries in recent years.124–126 In contrast,
areas of Australia have shown small increases in time and resources
committed to physical education.95,127 This apparent depreciation ofphysical education is unfortunate as recent research has shown that
more MVPA is achieved on school days with a physical education
class (9 more minutes in the United States and 16 more minutes inFinland) compared with those without.128 These differences accountfor a significant proportion of time toward meeting physical activity
guidelines.84,129 The relative importance of school-based support
for physical activity may be greater in HICs where organized andstructured physical activity is disproportionately relied upon.
School.

Community and the Built Environment. For this indicator 3

countries (Netherlands,44 Australia,24 Canada27) had grades in the
A range while Ghana,35 Mozambique,43 and Zimbabwe61 reported F
grades. Eleven countries reported an INC grade. All countries with

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a grade of C+ or higher were HICs whereas 7 out of 9 countries
with a grade of C- or lower were LMICs. Grades from participating
countries in North America and Europe were higher than thosefrom other continents. The general pattern of higher grades in HICs
and lower grades in LMICs was consistent with the Global Matrix
1.0 and makes intuitive sense. The importance of improving thebuilt environment to facilitate healthy active living and making thehealthy choice the easy choice has gained significant popularity,especially in HICs.130 However, several countries report that the
infrastructure for this indicator is already quite good. Countries
with high grades for this indicator reported rather good physicalactivity infrastructure, availability, and programming,24,27,31,38,44
but often without the desired impact on habitual physical activity.
In fact, the Spearman’s rho for the Overall Physical Activity grade~ Community and Built Environment grade is –0.28 (P = .18) andindicates an overall negative relationship, albeit weak.
Characteristics of the built environment are a potential sourceof influence on the physical activity level of children, youth, andadults. In a study using latent class analysis of built environment features reported by adults from 11 countries, 2 specific neighborhood
patterns were positively associated with meeting physical activity
guidelines: an overall activity supportive environment (eg, many
shops and transit stops within walking distance, sidewalks on moststreets, low-cost recreation facilities near-by) and highly walkableyet unsafe environments with few recreation amenities.131 The IPEN
study also examined the associations between objectively measured
characteristics of the environment and objectively measured physicalactivity in 14 countries, finding that residential density, intersection density, public transport density, and the number of parks in a
0.5 km buffer were linearly and positively associated to MVPA.132
Similar results were obtained in a descriptive review examining theassociation between children’s physical activity and environmental
attributes among 33 quantitative studies.133 Children’s participation in physical activity was found to be positively associated withpublicly provided recreational infrastructure (eg, access to recreational facilities and schools) and specific transport infrastructure(eg, presence of sidewalks and controlled intersections, access todestinations and public transportation) and negatively associatedwith more roads to cross, increased traffic density and speed, andunsafe local conditions.133
While it is intuitive and perhaps obvious that physical activity–promoting environments will encourage and ultimately lead toan increase in childhood physical activity, we need to be open to thepossibility that either the perception of what constitutes a physicalactivity promoting environment may be incorrect, or that the built
environment, organizational structure, or facilities alone may beinsufficient to have a demonstrable impact on childhood physicalactivity levels. The physical, organizational, and social structure–
centric approach commonly employed and seemingly preferred in
HIC is arguably not working. As stated in the Global Matrix 1.0
article,15 “in some cases it may be that ‘less is more’ for the promotion of exploratory play and incidental physical activity for somechildren,” as seen more so in LMICs. This “less is more” approachis also supported by the Position Statement on Active Outdoor Playreferred to earlier,78–80 which is less cost-intensive, is fundamentallymore accessible for vulnerable, marginalized, rural, and remote
populations, and is rooted in history. An increase in independence,
including greater independent mobility and freedom to play, may
turn out to be more effective at increasing habitual physical activity
than more structured approaches. Playing outdoors in nature (eg,unstructured fields, bushes) might be more attractive to children
than structured, hyper-safe yet unchallenging playgrounds. Basedon the findings from the Global Matrix 2.0, such an approach atleast deserves consideration and will require more social engineering than built environment engineering.
Government Strategies and Investments. Denmark31 reported

the highest (A-) grade for the Government Strategies andInvestments indicator followed by Slovenia51 and the United ArabEmirates57 (B+). Twelve other countries reported grades in the B
range while only 1 country (Mozambique43) reported an F grade.
In contrast to the Global Matrix 1.0 where 5 out of 15 countries
assigned an INC grade, only 6 out of 38 countries in the Global
Matrix 2.0 assigned INC grades. The continental average grades
were rather uniform around the world, regardless of country HDI.
The individual country Report Cards24–61 serve as a repository of
government policies, strategies, and investments; however, a paucityof robust evaluations reduces the strength of the guidance that canbe gleaned from these listings.
While most countries reported adequate to good government
physical activity strategies and policies, several also noted a serious
lack of implementation and dearth of quality assurance or evaluation. This policy–implementation disconnect may help to partiallyexplain the paradox observed with greater infrastructure and support sometimes negatively associated with actual physical activity
behavior. Implementation deficiencies can coexist with insufficientsustainability and scalability. Also plausible is the possibility thatthe social-cultural environment (eg, parental restrictions/societal
norms on active and outdoor play) is counteracting what mightotherwise be favorable policies and strategies for physical activity.
Finally, policies and strategies may be reactive, rather than preventive, to problems after they had emerged, thus making evidence ofeffectiveness more difficult to demonstrate. Regardless, it remains
prudent advice “to rally support for the implementation of proactive
campaigns, strategies, and investments in developing countries inan effort to preserve inherent healthy active living behaviours.”15
Other Indicators. Many countries included additional indicatorsof country, cultural, professional, or political importance. These
results are not presented or discussed in this paper, but examplesof additional indicators included body weight status, nutrition/
healthy eating indicators, physical fitness, movement skills, andnongovernmental strategies and investments, among others. Details
are reported in individual country Report Cards.24–61

Disparities and Inequities
Disparities and inequities are evident and variable in the Global
Matrix 2.0 in several ways. The most obvious may be at the country
level with some countries reporting better grades than others. It is
this variation that makes the process informative and can lead toinsights that may help to “level the playing field” across countries.
Also obvious from an examination of the individual country Report
Cards24–61 is the lack of data and consequent discussion related tochildren and youth with a disability (physical, mental, sensory),
similar to the Global Matrix 1.0.15 This large and particularly
vulnerable group arguably has the most to gain from a “level playing field.” The prevalence of children and youth with disabilities
varies substantially among countries and disability category134,135
and the Global Matrix process could help to identify and circulate
best-practice strategies.
Similar to the Global Matrix 1.0, the most notable withincountry disparity or inequity was seen with the Organized Sport
Participation indicator, likely because of the resource requirement for registration fees, equipment, and travel. This disparity is

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S358  Tremblay et alevident with socioeconomic (favoring middle- and high-income),
geographic (favoring urban dwelling), and sex (favoring boys)
gradients. The attention paid to such gradients in most Report
Cards was rather superficial and represents an important area for
improvement in future international comparison efforts. Indeed,
the strong and significant negative correlation seen between boththe Gini Index63 and Gender Inequality Index,64 and Sources ofInfluence for physical activity (Table 5) suggests that country levelindices of inequality and empowerment may be important targets,or beacons, for innovative interventions.
Other international comparison research has shown interesting
interactions between physical activity and outcome indicators acrossfamily-level sociodemographic gradients as well as country-levelindices such as HDI and Gini Index. For example, the International Study of Childhood Obesity, Lifestyle, and the Environment(ISCOLE),136 which collected data on 9- to 11-year-old children in
12 countries varying widely on HDI, found opposite relationships
between family socioeconomic indicators (ie, income and education) and physical activity and obesity levels16,21,22 between HICs
and LMICs. Child physical activity levels were higher in higherincome households in HICs but lower in higher-income households
in LMICs.21,22 Child obesity levels were lower in higher-income
households in HICs and higher in higher-income households in
LMICs.16,21 Clearly there is much to learn from such disparities
and inequities and much further to be understood and this should
be a priority focus for future comparison initiatives.

Data Gaps and Research Priorities
The high proportion of incomplete grades (INC), especially for the
Active Play and Family and Peers indicators, suggests there is a needfor clearer definitions and more thorough data collection methods
in most countries. Furthermore, in many countries there is a lackof nationally representative data, and the extent to which inherent
biases in existing data distort the true situation is unknown. The
collection of data using harmonized measures, including objective measures of physical activity, on larger, more representative
samples would improve the validity and reliability of the findings,
while also adding greater resolution on within- and between-country
differences by sex, age, socioeconomic status, urban/rural living,
cultural minorities, children and youth with a disability, and otherpopulation stratifications that could help inform future strategies
and interventions to improve the grade. Expert recommendations
for physical activity surveillance have been published recently
in the United States.137 Specific future surveillance and research
priorities include:• Expanding the Global Matrix (ie, 3.0) to include even greater
global representation (current areas with less representation
include the Middle East, South America, Pacific Islands, Caribbean, Russia; see Figure 1)• Using robust, standardized measures of physical activity andsedentary behaviors on children and youth from countries
around the world• Standardization of interpretation of accelerometer data using
agreed upon cut-points for accelerometer types• Developing a clear accepted definition and valid and reliablemeasures of active play
• Developing valid and reliable measures of the influence offamily and peers on physical activity behaviors of children andyouth• Further prospective multicountry intervention research on thedeterminants of physical activity and sedentary behaviors inchildren and youth from countries at different stages of thephysical activity transition19• The measurement and surveillance of healthy movement behaviors information (including physical activities of all intensities,
sedentary behaviors, and sleep) on young children (toddlers
and preschoolers, aged 1 to 5 years) from countries around theworld to understand and inform best practices for the promotionof healthy growth and developmental trajectories83• An extension of measures to include emerging health behaviors
that have not been typically measured in the past (eg, sitting
time, breaks in sitting time, nonscreen time sedentary behaviors,
screen time multitasking, emerging screen time subcomponents
analyses (eg, texting, Skype), light physical activity) and further research to understand their relationship with health andwellbeing indicators in childhood• Adding physical fitness as an indicator in future Report Card
comparisons• Further research and surveillance of marginalized groups,
including children and youth with a disability, new immigrants
and refugees, and rural and remote communities, as well as
income and ethnic disparities• Further evaluation of policies and programs intended to promote
physical activity among children and youth, to identify the bestand scalable practices, and how they can be best implemented
in differing settings• Cost effectiveness studies of strategies to improve physicalactivity and sedentary behaviors in children and youth• Exploration of current surveillance practices at the country level
to delineate which variables are over- and under-surveyed (eg,the Scotland 2016 Report Card50 revealed over-surveillanceof Active Transportation with 4 different national surveys, incontrast to no surveillance of Active Play or Organized Sport
Participation).
Unrelated to the Global Matrix 2.0 project, a Delphi survey ofinternational experts established research priorities for child andadolescent physical activity and sedentary behavior,138 with the top
priorities being development of effective and sustainable interventions to increase long-term physical activity among children andyouth; assessment of policy and/or environmental changes and theirinfluence on physical activity and sedentary behaviors of children
and youth; and implementation of prospective, longitudinal studies
to examine the independent effects of physical activity and sedentary
behaviors on health from birth to middle age.138

Recommendations for Improving the Grades
and Future Directions
Recommendations to improve the grades were forwarded by country
Report Card leaders (coauthors of this paper) and include (presented
in random order):• Promoting and reducing restrictions (eg, over-protectionism)
for active play
• Prioritizing the establishment and preservation of safe environments for active play and unstructured physical activity• Promoting and facilitating safe active transport to school andother destinations

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Global Matrix 2.0 Report Card Grades   S359

• Ensuring schools have comprehensive physical activity policies
in place that outline ways to encourage and engage students inphysical activity throughout the entire school day to promote
physical, mental, social, and academic benefits. For example,
in addition to formal physical education classes, schools should
promote in-class physical activity breaks. This should be developed in consultation with teachers, parents, and students andreviewed over the course of a school year
• Promising and scalable community interventions in public
spaces represent an opportunity to promote physical activity
in a socially inclusive environment that could contribute to
decrease in the unequal access to recreational opportunities,
mainly in LMIC.139,140 For example, Ciclovías or Open Streets
programs, implemented in at least 12 out of the 38 countries
participating in the Global Matrix 2.0, are globally recognized
as a program to promote physical activity. However, the impactof these programs on children’s physical activity levels requires
evaluation.
• Improving physical activity and sedentary behavior surveillanceby implementing systematic and robust measures (eg, use ofobjective measures like accelerometry and validated questionnaires) on representative samples across all childhood ages (eg,toddlers through to adolescents)• Evaluating the implementation, efficacy, and effectiveness ofnational strategies and policies• Establishing culturally and geographically (eg, urban vs. rural)appropriate policy interventions and programs• Ensuring that children, young people, and their families arecontinually educated on the importance of balancing different
types of sedentary behaviors, especially since some are more
likely to be detrimental than others (eg, screen time for entertainment vs. study for school vs. reading a book). Parents could
use autonomous and supportive parenting practices, whereby
they involve children in the formation of household rules andconsequences/rewards• Ensuring the acquisition of fundamental motor skills in earlychildhood to increase self-efficacy and habitual physical activity• Encouraging and supporting organized sports clubs to be more
inclusive to reduce gender and social inequalities in organized
sports participation and also reach the less sports talented.

Strengths and Limitations
The Global Matrix 2.0 initiative has several strengths, including the>150% expansion in the number of participating countries comparedwith Global Matrix 1.0, the commensurate expansion in the geographical distribution allowing for insights from more genuinely
global data, capacity development (see Table 6 for selected quotes
from country participants), the clear and transparent identificationof data gaps and research needs, the ability to run some statisticalcomparisons, the facilitation of research collaborations and professional networking, and the formation of a team passionately committed to improving the current and future health and wellbeing ofchildren through increased physical activity.
While the Global Matrix 2.0 represents a significant improvement over the Global Matrix 1.0,15 there remain significant limitations and room for improvement. The substantial variation in thequality and quantity of data used to inform the grades between

countries remains the greatest limitation to the comparison process.
Despite this serious limitation, country leaders believe that theconvening of a diverse set of country experts, presented with thecollection of the best available data, represents the most authentic
and robust method presently available to make such comprehensive comparisons across countries. A recent article examining thecorrelates of agreement between accelerometry and self-reported
physical activity data demonstrated systematic cultural and sociodemographic differences raising questions about the comparability ofphysical activity data across countries.141 This concern, althoughdemonstrated in adults, lends some support to the comprehensive
data synthesis approach taken in the development and grading of
the Report Cards.12 Other limitations of the Global Matrix 2.0
include the lack of inclusion of most of the world’s countries; little
exploration of disparities and inequities across ability levels, gender,socioeconomic status, or urban vs. rural dwelling; no formal auditing procedure for assigned grades; and lack of clarity on indicatordefinitions and benchmarks. It is hoped that the Global Matrix 3.0
will show substantial progress toward mitigating these limitations.
To this end, country leaders participating in the Global Matrix 2.0
met in Bangkok immediately after the 2016 International Congress
on Physical Activity and Public Health to debrief on the experience,
expose limitations to within- and between-country comparisons, anddiscuss potential improvements for the Global Matrix 3.0.

Conclusion
The Global Matrix 2.0 provides a comprehensive summary of physical activity behavior and sources of influence indicators from 38
countries using a harmonized data gathering, assessing, and grading
process. The results suggest a complex network of strengths andlimitations across countries, with some global patterns emerging
when comparing countries clustered by continent, HDI,62 andinequality.63–65 There is some evidence of higher physical activity
and lower sedentary behavior in countries reporting poorer infrastructure and a greater reliance on Active Play and Active Transportation; and lower physical activity and higher sedentary behavior incountries reporting better infrastructure and a greater reliance on
Organized Sport Participation and better School and Community
facilities and policies. This paradox suggests autonomy to play
and greater independent mobility rather than infrastructure andstructured activities may facilitate higher levels of physical activity.
The Global Matrix 2.0 serves as a source of information forresearchers, advocates, practitioners, and policy-makers to learn
from and build upon. Moreover, the Global Matrix 2.0 is an effective medium for capacity development, especially in LMICs. It
facilitates professional networking, cross-fertilization of ideas,
conceptualization of strategies and solutions, inception of researchcollaborations, promotion of advocacy synergy, momentum forchange, and inspiration for future work. In the ongoing effort toovercome the persistent and pervasive challenge of increasing
childhood physical activity, and to “power the movement to get kids
moving,” it is recommended that the Global Matrix framework be
expanded, improved, and repeated.
Acknowledgments
The authors would like to acknowledge Active Healthy Kids Canada fordeveloping the Report Card methodology. The authors are indebted tothe individual country Research Work Group members and Report Card
Project Managers and/or Scientific Officers, including Charlie Vincent

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Japan

India

Ghana

Colombia

The childhood inactivity crisis is one that many countries are facing. The Global Matrix 2.0 provides a united forum for us all to work toward a common goal; that is, getting
the children of today and tomorrow to “move more and sit less”. By bringing together 38 countries to internationally benchmark 9 physical activity indicators, the Global
Matrix 2.0 allows Australia to compare how well it is performing in promoting and facilitating physical activity opportunities relative to the rest of the world. We believe thatparticipation in the Global matrix 2.0 will help AHKA to inspire change, and facilitate advocacy and strengthen national, state and community efforts aimed at increasing
physical activity and reducing sedentary behavior in young Australians.

Australia– Chiaki Tanaka(continued)

The report card also inspired us to start planning a report card for each of Japan’s 47 prefectures increasing cooperation among researchers and academics and hopefully
leading to an improvement in physical activity in children and adolescents across Japan.

However, working on the global report card has made it clear that Japan doesn’t have enough data on physical activity for children and adolescents to grade overall physicalactivity levels. This has been quite disappointing/frustrating but has raised some interesting questions and inspired our team to discuss how to best evaluate physical activity
in Japan. For example, could sum of exercise and active play time outside of physical education classes be used in future report cards to evaluate overall physical activity
levels? Evaluation methods used by other countries in Matrix 2.0 can also provide examples on effective cross-national ways to evaluate physical activity for the Japanese
government and researchers in the field.

The Global Matrix 2.0 has been an incredible opportunity to collaborate with researchers and academics across Japan and from around the world. It has been a challenging
and exciting experience that I hope will influence not only government policy but also how the public views physical activity in our children and adolescents.

– Tarun Katapally

It has been an incredible experience to be a part of a complex collaborative effort between active living researchers around the world. I am confident that this knowledge
exchange endeavor across countries can initiate changes in how governments and stakeholders look at the value of promoting physical activity among children.

– Reginald Ocansey

Two intervention strategies that are intended to raise the grades on physical activity indicators for children and youth in Ghana are underway. They include; (1) a Physical
Education and School Sports Policy to support the conduct, monitoring and surveillance of physical activity in physical education in school as well as after-school sportsand (2) a Community-Based Coaching Program to support after-school and community sports requirements. Both interventions possess the power to encourage children andyouth to move to increase their physical activity levels.

Ghana’s maiden Report Card on Physical Activity for Children and Youth, published in 2014, established a baseline description of physical activity indicators of Ghanaian
children and youth and has since influenced stakeholders to start developing policy guidelines and interventions to raise the grades on physical activity indicators for children and youth in the future.

– Silvia Alejandra Gonzalez Cifuentes

Participation in the Global Matrix 2.0 has been a unique opportunity for the group in Colombia to contribute to the surveillance agenda in the country. Based on the 9common indicators included in the Global Matrix, new indicators on physical activity for the National Survey of Nutrition in Colombia have been proposed and are being
collected at the national level for the upcoming version of the survey. We also consider that the comparisons with other countries, and for the first time with other countries
from the South American region, provide a great opportunity to learn from the successful efforts of other nations to promote active and healthy lifestyles among children andyouth.

– Grant Tomkinson and Natasha Schranz

Quote

Selected Quotes From Participating Country LeadersCountry

Table 6

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S361

Zimbabwe

United States

Slovenia

Scotland

New ZealandParticipating in this edition for the 2016 Report Card for Children in México and the Global Matrix 2.0, has been an extraordinary experience. It has been an honor to be
involved with such distinguished researchers from around the world, but most importantly, working with a very talented and extraordinary young group in México has been
beyond my expectations.

Mexico– Taru Manyanga

Being part of the Global Matrix 2.0 has been a great privilege, honor and an enriching experience at both personal and academic levels for me. Coleading the development of
Zimbabwe’s first ever Report Card introduced me to this incredible global network of dedicated scientists, policy makers and researchers. The process exposed me to a great
network of local researchers and other influential stakeholders. Only through such genuine global efforts can we learn from, and with each other as peers. There is no doubt
in my mind about the importance and positive impact of the report card to our efforts in promoting active and healthy lifestyles among Zimbabwean children and youth. Thishas been an incredible experience for me.

– Peter Katzmarzyk

The US Report Card is a major collaboration among partners of the National Physical Activity Plan Alliance. Having the Report Card initiative under this umbrella has beenvery rewarding as it allows for the rapid uptake of the results with organizations that can respond with strategies to improve the grades.

– Shawnda Morrison

It is a fantastic opportunity for the Republic of Slovenia to be involved in the Global Matrix 2.0. not just to see where our country ranks in terms of overall physical activity
patterns in children and youth globally, but also as a way of communicating the current state of research and policy within Slovenia to a wider audience.

– John Reilly

The launch of the global matrix provided an important insight into why physical activity levels are so low in Scottish children and adolescents. The comparative approachto physical activity in the global matrix revealed that “we have built it but they have not come”: having good policy and physical environments for child physical activity is
insufficient to create active healthy children.

The global matrix should have substantial impact in Scotland — the grades from Scottish children and adolescents did not compare favorably with the rest of the world,
attracting a great deal of publicity. Seeing our position relative to other nations has provided impetus to do better in future physical activity and health policy.

– Member of New Zealand Report Card Committee

For me personally, involvement in this project has been very valuable to become more aware of the existing national datasets and reports that describe different physicalactivity indicators in New Zealand and experience the process of creating this national-level report. But the most valuable experience for me was the opportunity to connect
and work together with other academics and researchers across New Zealand. I hope that this work will be a springboard for future national-level collaborations in the physical activity field in New Zealand.

– Juan Lopez Taylor

Quote

Country

Table 6 (continued)

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S362  Tremblay et al(Australia); Anne I. Wijtzes (Belgium); Allana LeBlanc and Brett Bartlett(Canada); Andrea Cortínez-O’Ryan (Chile); Peijie Chen (China); Olga
Lucia Sarmiento (Colombia); Hannah Wilkie (England); Helena Kruusamäe and Merike KullMarcella (Estonia); Katariina Kämppi (Finland);Richmond Aryeetey and Seidu Sofo (Ghana); Deirdre Harrington (Ireland);Stella Muthuri and Sylvester Hayker (Kenya); Karla I. Galaviz (Mexico);
Universidade Pedagógica (Mozambique); Marcella Burghard (the Netherlands); Eiman Al-Hammadi (Qatar); Adrienne Hughes (Scotland); Gregor
Starc and Vedrana Sember (Slovenia); Monika Uys (South Africa); Lluís
Serra-Majem (Spain); Mouza Eid Al Zaabi (United Arab Emirates); Kara
Denstel (United States); Betty Méndez-Pérez (Venezuela); Richard Tyler(Wales); Daga Makaza (Zimbabwe). The Hong Kong Report Card was
supported by a Knowledge Transfer Fund from the Chinese University ofHong Kong (#KPF15ICF12). The Thailand Report Card Team thanks theThai Health Promotion Foundation and Thailand Physical Activity ResearchCenter for their funding and administrative supports.

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