Global Matrix 3.0 physical activity report card for children and youth: a comparison across Europe

Objectives: The Global Matrix of report card grades on physical activity serves as a public health awareness tool by summarising the status of child and youth physical activity prevalence and action. The objectives were to: (1) provide a detailed examination of the evidence informing the ‘ School ’ and ‘ Community and Environment ’ indicators across all participating European Global Matrix 3.0 countries; (2) explore the comparability of the grades for these two indicators across Europe; (3) detail any limi- tations or issues with the methods used to assign grades; and (4) provide suggestions on how future grading of the indicators could be improved. Study design: A comparative review of published methods on the grading of Global Matrix 3.0 indicators across European countries. Methods: Key documents relating to the European countries involved in the 2018 Global Matrix 3.0 were collated and a template used to extract data for both the ‘ School ’ and ‘ Community and Environment ’ indicators. Results: Seventeen of the 20 European Report Card countries (85%) had a grade for schools, and 15 countries (75%) had a grade for community and environment. All countries considered between one and ﬁ ve factors when assigning the grade for these indicators. There were wide disparities in the number and sources of evidence used to assign the grades for both indicators, limiting the comparability of the evidence between different countries. Conclusion: To enable comparability, the authors recommend moving towards an agreed standardised set of metrics for grading each indicator. Furthermore, it would be useful to develop and share common tools, methods and instruments to collect data in a uniform way across countries, where possible. Such action will ultimately make the Global Matrix a more robust and useful tool for the future.


Introduction
Reaching a sufficient level of moderate-to-vigorous physical activity (MVPA) is recognised as a key determinant of health. 1 Yet, an estimated 80.9% of youth (11e17 years) in Central and Eastern Europe do not reach the minimum recommendation of 60 min of daily MVPA. 2 This is disturbing, as physical inactivity among school-aged children and youth has been found to be associated with adverse physical, mental, social and cognitive health outcomes, lower physical fitness, as well as lower physical activity levels in adulthood. 3e6 The Global Matrix of Physical Activity Report Cards was launched in 2014 to benchmark physical activity promotion efforts targeted at children and youth. The matrix serves as an advocacy and information tool for decision makers and stakeholders from across the world by highlighting the global variation in physical activity prevalence and promotion across different countries and where representative data are lacking for specific indicators within countries.
A total of 15 and 38 countries took part in the Global Matrix 1.0 (2014) 7 and 2.0 (2016), 8 respectively. In 2018, the Global Matrix 3.0 was initiated, involving 49 countries in the harmonised procedure to develop national report cards. Ten common indicators (see Box 1) were assigned a letter grade (Aþ to F) by using common benchmarks to guide the grade assignment process. 7 When grading was not possible, typically due to insufficient data, a grading of INC (incomplete) was assigned. A total of 490 grades, including 369 letter grades and 121 INC grades, were assigned in the Global Matrix 3.0. 9 The Global Matrix 3.0 confirmed that physical activity levels of children and youth are low, 9 and actions to reduce inactivity are variable across Europe. 10 Schools and the wider community and environment are critical influences on the physical activity levels of children and youth; 11e14 therefore, changes in these indicators have the potential to affect many children. Consequently, we sought to examine the factors considered when assigning these grades across European countries, to inform future practice. The objectives were to: (1) provide a detailed examination of the evidence informing the 'School' and 'Community and Environment' indicators across all participating European countries; (2) explore the comparability of the grades for these two indicators across Europe; (3) detail any limitations or issues with the methods used to assign grades; and (4) provide suggestions on how future grading of the indicators could be improved.

Methods
A total of 20 European countries contributed to the Global Matrix 3.0 (see Table 1 for a summary of grades). The process for assignment of the grades involved the establishment of a team within each country that developed a set of indicators and appraised the country's performance. The process and grades are published in long and short forms, as well as in the main scientific paper (www.activehealthykids.ca). Key documents relating to the participating European countries were collated. A template was developed to aid with data extraction (see Additional file 1), which captured information on: the grade assigned for each indicator; details of the data used to assign the grade; the source of the data; an indication of the quality of the data; and any reported issues or challenges in assigning the grade.
The template was piloted whereby four members of the team (AC, EM, KM and TC) each completed the template for two countries. The data were reviewed to determine consistency in the types of information and the level of detail provided. Where inconsistencies were evident, revisions to the template were made and more explicit guidance on completion was added. Only publicly available information contained within the scientific and/or long and short forms of the report cards was used, and only sources of evidence used to inform the 2018 report card grade were considered. Subsequently, all members of the team were informed on how to use the template and what information was to be extracted.
The relevant team member(s) took responsibility for leading the data extraction for their own country. All other countries were allocated arbitrarily among the team members. If anything was unclear or information was unavailable, the original author and/or country card lead for that country was contacted for further information.

Fig. 1 displays the School and Community and Environment grades for European countries.
Schools Table 2 provides a summary of the factors used to assign the school grade for each country. In total, 17 of the 20 European Report Card countries (85%) had a grade for schools, using between one and five school factors to assign their grade. Guernsey, Scotland and Wales did not have a grade for schools and were excluded (shaded in Table 2). Details of the factors considered in assigning the grades are provided below in order of the number of countries using that factor.

Physical education
The most frequently reported factor on which the school grades were based was physical education (PE), with all but two countries (Finland and the Netherlands) considering this indicator (n ¼ 15). For some countries, this indicator was based on PE being compulsory, as mandatory in legislation (Czech Republic, Estonia, Germany, Lithuania, Portugal, Slovenia and Sweden). In addition to mandatory PE, some countries were asked to self-report their adherence to the legislative requirement, which was also considered when assigning the grade (Denmark, France, Jersey and Spain). For one country, the average minutes of PE offered to pupils were used (England). For some countries, the PE indicator was based on the proportion of children reporting to take part in a mandatory amount of PE (Belgium and Poland). For Bulgaria, the indicator was based on children and their parents' assessment of the quality of PE classes.

Qualifications/quality of teachers delivering PE
Two-thirds of schools that considered PE as a factor also considered the qualifications or quality of the teachers responsible for PE (n ¼ 10). For France, this indicator was based on it being mandatory for PE lessons (in high schools) to be delivered by a trained specialist. For the majority, however, it was based on the proportion of PE teachers with specialist PE training (Belgium, Czech Republic, Denmark, England, Estonia, Germany and Lithuania). Bulgaria used children and their parents' perceptions of the quality of teachers; Slovenia reported that they have 'highly competent PE teachers' with no further explanation offered.

Box 1
The 10 indicators in the Global Matrix 3.0.
Overall physical activity Organised sports and physical activity Active play Active transportation Sedentary behaviours Physical fitness Family and peers School Community and environment Government

Sports facilities/equipment
The quality of physical activity and sports facilities and equipment at school was considered in less than half of the included countries (n ¼ 8). For most countries, this factor was based on 'access' to facilities and equipment (Czech Republic, England, Germany, Jersey, the Netherlands and Slovenia). Bulgaria based this factor on children and parents' views on the quality of sports facilities at school. Denmark considered both access and teacher appraised quality.

Active school policies
Six countries considered the number of schools that had developed policies that promote physical activity as part of the school day (Czech Republic, Denmark, England, Finland, Jersey and Lithuania).

After school/extra-curricular sports and physical activity
Five countries considered the provision of after school/extracurricular activities (Belgium, Czech Republic, England, Estonia  Active play  INC Cþ  DÀ DÀ  INC INC F  CÀ  C  INC INC INC INC B  INC INC INC INC D  CÀ  Active transport Cþ and Slovenia), which was based on the availability of physical activity and sports opportunities. Estonia also included having an opportunity to take part in sports competitions out-of-school hours.

Sports and physical activity during recess/lunch
The provision of pupil-reported physical activity opportunities during break and lunch times was considered in two countries (Estonia and Spain).

National active school initiative
Taking part in a national 'active school' initiative was considered in two countries (Finland and Slovenia). The school grade for Finland was exclusively based on the number of schools participating in the Finnish Schools on the Move initiative, 15 which aims to add physical activity opportunities into a recess and academic lessons. In Slovenia, the Healthy Lifestyle Programme was introduced to build more and better-quality physical activity opportunities into primary schools, with two additional PE lessons per week.

Health education lessons
One country (Belgium) specifically referred to 'health education' lessons as distinct from PE.

Access to facilities outside of school hours
Only Spain considered the accessibility of sports facilities outside of school hours to be important in assigning the school grade.

Community and environment
Overall, 15 countries (75%) had a grade for the community and environment, and Table 3 provides a summary of the one to five factors considered when assigning the grade. France, Guernsey, the Netherlands, Spain and Wales did not have a grade and were excluded from the analysis (shaded in Table 3). Details of the factors considered in assigning the grades are provided below, in order of the number of countries using that factor.

Perceptions of neighbourhood safety
The most frequently considered factor of the Community and Environment was perceptions of neighbourhood safety, which was considered in 10 of the 15 countries (Belgium, Bulgaria, Czech Republic, England, Estonia, Germany, Jersey, Lithuania, Scotland and Sweden). In three countries, this was based on the proportion of children that reported living in a safe neighbourhood where they can be physically active (Czech Republic Estonia and Sweden), whereas in four other countries, the judgement was based on parental ratings of safety (England, Germany, Lithuania and Scotland). In Jersey, the rating could be made by children or parents, and in Bulgaria, it was not specified whose perception was considered. Belgium was the only country to consider specific aspects of safety including road traffic and crime.

Parks/green space
A total of eight countries considered an indicator of parks and green space. For some countries, this indicator was based on the presence of public playgrounds in communities (Germany) or the proportion of children with access to a park (England), with no further detail on how these indicators were assessed. In Belgium  and Bulgaria, the indicator was explicitly based on children reporting easy access to parks. In Scotland, the rating was based on the number of children with at least one play area within their neighbourhood, and in Sweden, it was based on the proportion of children with access to green space within 300 m of their home. In the Czech Republic, access to parks was assessed objectively via a geographic information system. In addition to the presence of green space, the extent to which parks and playgrounds are well maintained was factored into the grade assigned in Belgium. The grade in Jersey was based on perceptions of maintenance of parks, rather than provision.
Sports/recreation facilities A total of eight countries considered sports and recreational facilities when assigning the Community and Environment grade. For two countries, this was based on children's self-reported access to facilities (Bulgaria and Denmark); for one, it was based on once per week usage (England) and another considered resident satisfaction with sports and recreational facilities (Belgium). In Estonia, the importance of accessible sporting facilities was acknowledged, although no system was in place for assessing provision. Similarly, in Germany, most cities provided facilities such as soccer pitches, although it was not clear how such provision was assessed. As with parks and green space, the grade for Jersey was based on perceptions of maintenance of facilities, rather than provision. In Finland, the grade was based on school facilities and sports grounds being provided free of charge. In Denmark, in addition to the proportion of children reporting access to sporting facilities, the equitability of access was taken into consideration.

Supportive environments/opportunities
Four countries considered whether residents perceived the neighbourhood environment to be supportive of physical activity. These perceptions came from children and adolescents (Denmark and Poland), parents (Lithuania), or not specified (Portugal).

Supportive policies
The presence of supportive policies for physical activity was factored into the grade assigned to three countries (Finland, Jersey and Slovenia). Jersey based their grade partly on the Fit for the Future strategy, 16 which committed to investing in infrastructure for physical activity. The grade in Slovenia was largely based on the legal requirement for municipalities to produce an annual programme of sport, whereas Finland considered the proportion of municipalities with a physical activity strategy.

Sidewalks/cycle paths
Two countries considered children's self-reported access to sidewalks and/or cycle paths (Belgium and Bulgaria).

Health promotion programmes/initiatives
In Lithuania, the grade was partly based on the number of municipalities implementing health promotion programmes.

The public's value of physical activity and sport
In Jersey, the grade was partly based on the proportion of the public that perceives sport and physical activity as important and valued.

Discussion
This analysis provides a comparison of the factors considered when assigning the grades for the School and Community and Environment indicators of the Global Matrix 3.0 on physical activity for children and youth among participating European countries.
Of 17 European countries (85%) that had a grade for schools, PE was the most common factor considered when assigning the grade, followed by qualifications/quality of teachers delivering PE and sports facilities/equipment. The current evidence-base suggests that whole-of-school programmes that include multiple components across the whole school day are most effective for increasing physical activity levels in the school setting. 14 Despite this, many countries considered just one or two specific actions when assigning their grade. This could introduce some bias in the results by providing an incomplete assessment and undermining the role of schools in providing opportunities for children's physical activity. For example, research indicates that having an active school travel policy can lead to increases in physical activity. 17 However, this was not considered when assigning the school grade, as active transportation (including to and from school) is a separate indicator in the Global Matrix. In addition, the playground environment was not explicitly considered by any of the included countries. It is possible that this was considered within the 'facilities and equipment' factor, whereby some parents and pupils were asked to rate the school facilities and equipment, but whether playgrounds were considered within this indicator was not explicit.
Of the 15 countries (75%) that had a grade for Community and Environment, perceptions of neighbourhood safety were the most common factor considered, followed by the presence of green space/parks and sports/recreation facilities. Research demonstrates that these are important indicators of children's physical activity. For example, positive associations have been found between perceptions of safety and physical activity in youth, with children who perceive their local areas as safe to be more likely to have higher levels of physical activity. 11 Conversely, crime is associated with a perceived lack of safety, and as a result, is often cited as a barrier to physical activity. 12 In addition, children (aged 9e12 years), whose parents perceived a higher presence of recreational facilities in their neighbourhood, have also been found to be more active in these recreational spaces. 13 There was a large variation in how the grades were assigned by different countries across Europe. Such subjective assessment may provide an unreliable comparison across Europe. This was evident in both the number and types of factors taken into consideration for each indicator. For the school indicator, for example, among the three countries that achieved grade A (Slovenia, Finland and Portugal), Slovenia based their grade on five factors (PE, qualifications/quality of teachers teaching PE, sports facilities/equipment, after school/extra-curricular sports and physical activity, national active school initiative); Finland on two factors (active school policies and national active school initiative) and Portugal on one element of school provision (PE). Similarly, in relation to Community and Environment, Sweden was graded an A based on two factors (perceptions of neighbourhood safety and green space/ parks) in comparison with Jersey, which was graded a C based on five factors (perceptions of neighbourhood safety, green space/ parks, sports/recreation facilities, supportive policies and sport perceived as valued). It is possible that Jersey may have scored higher if it had considered only the two factors that were considered by Sweden.
To increase comparability between countries and add clarity to the process, more detailed instructions for the indicators and benchmarks are needed. 18 This could be facilitated by a basic set of common metrics for each indicator. For example, given that 85% of European countries considered PE when assigning the school grade and two-thirds of countries based their Community and Environment grade on perceptions of safety, it may be beneficial for all European countries to use these metrics in the future, as standard.
In addition to a common metric, common sources of evidence should also be considered and/or the use of standardised questions or tools. For example, data related to schools, community and environment from the WHO Health Behavior in School-Aged Children (HBSC) survey 19 could be used as one of the common data sources due to it being used by 49 countries, every 4 years (http://www.hbsc.org/). The WHO Global Monitoring Framework, 20 which is being used to monitor implementation of the Global Action Plan on Physical Activity, 21 may also provide useful comparable data for some of the report card indicators.
It is also important to ensure that the factors considered when assigning grades for each indicator remain consistent over time. Spain was included in the Global Matrix 2016 when the National Active School Initiative was considered when assigning the school grade. Despite continuing to have the National Active School Initiative in 2018, as no 'new' sources of data were available, this and other factors were not taken into consideration. This may have led to a lower grade than warranted, due to failure to account for ongoing initiatives. It could also lead to confusion within a country as to whether these initiatives are in place.
Despite the differences highlighted with each of indicators, there does appear to be some commonality among the countries. Slovenia, Finland and Denmark are the countries scoring best for both indicators (A or AÀ for school, B or Bþ for community). Future research would benefit from examining these countries in more detail to determine what lessons could be learnt and applied to other countries in the region. This is the first study globally to scrutinise the comparability of the report card indicators globally. Moreover, it did so following a systematic process, minimising the likelihood of misreporting. The biggest limitation of this study was that the main sources of data (i.e. the short and long forms of the report card and/or the scientific paper) were not all available for all countries. In addition, for some countries, the information was not available in an accessible format. For example, the short and long report cards were only available in the national language, not in English, for Estonia, Denmark and the Czech Republic. We liaised with contacts in these countries to populate the data extraction template in an attempt to overcome this limitation.
Although this paper only focused on the School and Community and Environment indicators, issues with comparability are likely to be present across all report card indicators. To improve the methods used for assigning grades for all report card indicators, the authors recommend: Advocating for common questions and/or tools to be used in nationally representative surveys; Providing information on the most commonly used metrics for assigning indicator grades globally; Providing future Global Report Card contacts with a mandatory/ basic metric that should be included to assign a grade. Based on our European analysis, we suggest 'PE' for the school grade and 'perceptions of safety' for the Community and Environment grade; Adopting standardised methods to conceptualise and measure all indicators to ensure clarity on the definitions used for all indicators and benchmarks to allow comparisons to be made across countries; Allocating more weighting to the factors for which there is strong evidence of effectiveness, for example, for the school indicator, whole-of-school policies to promote physical activity 14 and PE delivered by qualified teachers. 22 These factors should also become mandatory to assign the grade; and Requiring countries to provide more detail on the measurement method(s) used.
It should be acknowledged that the European region is one of the most advanced globally in terms of national surveillance of physical activity behaviour and its determinants. 23 Because of its capacity for surveillance, it is well-positioned to review and better align the methods used for assigning grades for the report card indicators across countries to improve comparability. In other parts of the world, and particularly low-and middle-income countries, surveillance systems are less well-established and resources are often limited. Furthermore, other parts of the world have important contextual differences, which present challenges to the ways in which data are collected and interpreted. It remains important to include these countries in such global initiatives, despite limitations in our ability to draw direct comparisons on the report card indicators. We propose that the European countries trial any standardised approaches developed for future indicators and benchmarks used in the Global Matrix initiative to explore whether more standardised approaches are possible, at least in some parts of the world.

Conclusion
Public health surveillance is the cornerstone of public health practice. 24 Surveillance of physical activity is essential for monitoring progress towards benchmarks, setting priorities and informing policy. 25 The Global Matrix provides a useful method of consolidating the best available evidence and information on children's physical activity and its promotion globally, enabling comparisons and trends to emerge. However, this study demonstrates that there is a high degree of variability in the factors and data sources used to assign grades in two key settings that impact children's physical activity. To enable comparability, the authors recommend moving towards an agreed standardised set of measures that all countries adhere to, where possible, which will ultimately make the Global Matrix a more robust and useful tool for the future.
Author statements extraction, which was undertaken by all authors with support from members of the HEPA Europe children and young people working group (see Acknowledgements). All authors contributed to writing and revising the manuscript. All authors approved the final version of the manuscript.