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The Welsh NHS Confederation response to the Health, Social Care and Sport Committee inquiry into physical activity of children and young people |
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Contact |
Nesta Lloyd – Jones, Policy and Public Affairs Manager, the Welsh NHS Confederation. XXXXXXXXXXXXXXXXXXXXXXXXXX Tel: XXXXXXXXXXXX
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Date: |
11 September 2017 |
Introduction
1. We welcome the opportunity to contribute to the Health, Social Care and Sport Committee inquiry into physical activity of children and young people. Being physically active is important to the whole population and should be encouraged from birth and promoted throughout people’s lives. We must ensure that everyone, no matter their age, background or geography, is supported to become and stay active in activities and in an intensity that is right for them.
2. The Welsh NHS Confederation represents the seven Health Boards and three NHS Trusts in Wales. The Welsh NHS Confederation supports our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work.
3. As well as this written submission, we also submit the Welsh NHS Confederation Policy Forum submission, “Getting Wales Physically active: Ten priorities to improve physical activity levels across the whole population to help improve health and well-being”,[i] endorsed by 20 health and social care organisations.
1. What do we know about physical activity levels in children in Wales? How robust is the data on this issue?
4. Our knowledge about the physical activity levels of children in Wales, and at Health Board level, is informed by data that is captured in self-reported surveys e.g. the Health Behaviour in School Aged Children (2013/14),[ii] Welsh Health Survey (until 2015)[iii] and the National Survey for Wales (from 2016/17).[iv]
5. The Health Behaviour is School Aged Children (HBSC) surveys children between the ages of 11-16 years. The HBSC dataset highlights that levels of physical activity in children in Wales is lower than the average for the 42 countries in Europe and North America represented. The most recent data (2013/14) stated that approximately 1 in 7 young people report being physically active for a total of at least 60 minutes every day in the last week (15% Welsh average), with girls being less active (11%) than boys (20%). The HBSC survey shows that rates of activity decline with age in both males and females. There is also variation by Local Health Board area but this variation is not statistically significant. There are statistically non-significant differences in this outcome by parents’ housing tenure and by material deprivation. The levels of participation in physical activity are not statistically different in 2014 compared to 2002.
6. The HBSC also has data on the proportion of children walking and cycling to school, with 32% across Wales and 34% males to 31% of females. Children from less affluent households are more likely to walk and cycle to school, ranging from 29% of those considered most affluent to 48% of those considered least affluent. There is also a statistically significant variation in walking or cycling to school by Local Health Board area, as highlighted below.
Proportion walking or cycling to school by LHB
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% walking or cycling |
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Males |
Females |
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Abertawe Bro Morgannwg |
25% |
22% |
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Aneurin Bevan |
44% |
38% |
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Betsi Cadwaladr |
36% |
34% |
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Cardiff & Vale |
48% |
40% |
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Cwm Taff |
28% |
25% |
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Hwyel Dda |
19% |
17% |
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Powys |
22% |
23% |
7. The most recent data from the Welsh Health Survey (2015)[v] tells us that amongst 4-15 year olds, 42% of males and 31% of females were active for at least one hour per day for 7 days in the past week e.g. enough physical activity to meet the recommended guidelines for health.
8. It is more difficult to determine if the activity the children are participating in is sufficient for health e.g. moderate to vigorous intensity and consisting of activities that strengthen muscle or bone. The survey asks how much exercise children aged 4-15 had undertaken on each day in the last week. In the question, “exercise” referred to physical activity that left the child feeling warm or slightly out of breath. The World Health Organisation defines moderate intensity physical activity as requiring “a moderate amount of effort and noticeably accelerates the heart rate; (approximately 3-6 METs)” and vigorous intensity physical activity as requiring “a large amount of effort and causes rapid breathing and a substantial increase in heart rate; (approximately >6 METs”. This difference in intensity and how many occasions are moderate intensity and how many are vigorous is not clear within the Welsh Health Survey.
9. From 2015 onwards the Welsh Health Survey was combined with a number of other social surveys in Wales, resulting in the National Survey for Wales.[vi] The survey includes a range of questions on sport and recreation but the methodology used is different to the previous Welsh Health Survey and as such there are some discontinuities in the data which might prevent continued comparison over time. Currently the survey focuses on people aged 16 years and over so does not provide data on children and physical activity levels.
10. The Sport Wales School Sport Survey[vii] is an online survey of pupils’ sports participation and school provision of Physical Education (PE) and sport. The 2015 surveyed 115,039 Year 3-11 pupils and found that 51.4% of males and 44.4% females were ‘hooked on sport’ e.g. take part in organised activity other than in curriculum time, for example extracurricular or club sport on three or more occasions per week. The survey also explores participation by year group, race, disability or impairment, free school meal quartile and welsh language.
11. The strength of these surveys is the large sample size. However, if we interpret ‘robust data’ in the context as meaning “data that is reliable and stable to input variations, thus presenting an accurate picture of reality both at once and over a period of time” the following limitations are noted:
· The surveys data is self-reported so this should be factored in when considering its robustness, including social desirability bias;
· Lack of consistency across surveys in age categories of children surveyed (4-15, 11-16, 3-17 year old);
· There is a lack of consistency in representation of sub-group characteristics such as gender and deprivation;
· There is incomparability of data across the Welsh Health Survey and the succeeding National Survey for Wales due to methodological differences;
· It is difficult to compare the data currently collected on physical activity participation as the focus is on different age groups;
· There is limited data on the type and intensity of physical activity that adults and children are participating in to really establish if that is adequate for related health benefits; and
· There is currently no data on physical activity participation available for infants and children up to 4 years of age. The School Health Research Network (SHRN)[viii] provides robust health and well-being data for schools, regional and national stakeholders.[ix] However no valid population level indicator of physical activity for children aged 0 to 4 in Wales exists, and we would advocate this being developed, including local population data (e.g. Health Board area) to inform service delivery.
12. Despite the above limitations, we are of the view that the data on physical activity levels in children in Wales gives a reliable picture of reality. Specifically, the sample sizes in the surveys are large enough to ensure that the estimates modeled from empirical survey data are robust.
2. Differences in gender-based attitudes towards, and opportunities for, participation in physical activity in Wales.
13. Attitudes are important as they are predictors of behaviours, including physical activity. Currently we are not aware of any gender based attitudinal data/information available at a local and/or Welsh level, only participation levels in Wales.
14. Some of the most authoritative UK secondary data on gender-based attitudes towards and barriers to physical activity came from NICE Public Health Collaborating Centre,[x] dating back to September 2007. There were no international studies included in that review as it was felt that the UK studies were sufficient. Notably however, much of the contributing research came from other UK nations, predominantly England. No primary research from Wales was included, ostensibly because they did not exist.
15. The Sport Wales School Sport Survey[xi] provides a range of data on attitudes to participating in physical education, school sport and extra-curricular sport, confidence in trying new activities and aspects that would encourage more participation in sport. Males tended to report that they would do more sport if: there were more sports that suited them (34.2%); that they had more time (32%) and if their friends went with them (31.4%). Females reported that they would do more sport if their friends went with them (48.1%); they had more time (39.6%) and if there were sports that suited them (35.3%). However, the survey primarily focuses on sport rather than physical activity more generally.
16. It is clear there are differences in gender-based attitudes toward physical activity participation but more insight work to understand these differences is needed in order to provide appropriate solutions. Behavioural insight can also be used to develop appropriate messages and effective targeted promotion of physical activity for specific groups where physical activity levels are lower e.g. women, minority ethnic communities and people with disabilities
17. We recommend that further consideration should be given to:
· Gathering insight of gender based attitudes towards physical activity, not just participation levels, and interpretation of findings to inform service delivery. This understanding would enable the NHS to identify the barriers, the enablers and what action needs to be taken, for example:
o Communication: How do we communicate the concept of physical activity?
o Type of activities: Is it heavily sport focused which might be less attractive to females, therefore less opportunity for them?
o Role of settings, peer pressure and role modelling: All have an impact on the different levels of participation seen in males and females; and
o Are current surveys placing too great an emphasis on organised sport as a measure of physical activity? Therefore, are we capturing the true picture?
18. While the lack of specific Welsh data on this subject is notable, given the availability of UK and international data Wales-specific data does not add actionable intelligence to the already-available body of knowledge.
3. The extent to which Welsh Government policies are aimed at whole populations and/or particular groups, and what impact that approach has on addressing health inequalities.
19. There are several Welsh Government policies that do attempt to strike the balance between universal and targeted interventions.
20. The Welsh Government physical activity policies, such as Creating an Active Wales,[xii] has a focus on whole populations. This policy aimed “to shift activity levels across the whole population to increase the average number of days that people in Wales are active”. One of its objectives is “to increase physical activity across all age, gender and social groups” and so recognises that all groups regardless of age, disability, gender or ethnic group, have the right to experience the health benefits of physical activity and would benefit from increasing the intensity and frequency of exercise. There were actions for specific population groups such as children and young people. In response, local physical activity partnership policies and action plans developed encompass whole populations and particular groups.
21. The Active Travel Action Plan for Wales highlights active travel as part of the daily routine for children and young people and the school setting and national curriculum in helping achieve this. The action plan goes on top state that “children and young people are a priority: active behaviours learnt and mainstreamed early will help establish healthy behaviours for life. We must create environments where children are safe to get around on foot or by bicycle for the journeys they want to make as part of their daily routines. Consulting with young people has been and continues to be a mandatory requirement for local authorities as they plan their active travel networks of the future”.
22. The Welsh Government Climbing Higher - Next Steps[xiii] recognises that there are specific groups that are known to reach key life stage/ages and communities where barriers to sport and physical activity are greatest. These include:
· Teenagers;
· Young adults leaving education;
· Adults having a family;
· Adults who are over 45/pre-retirement;
· In area of multiple deprivation;
· Amongst people with disabilities;
· In minority ethnic communities; and
· For women and girls generally.
23. Most policy and directive focuses on increasing physical activity levels across the whole population to improve health. Whole population polices are important, however there is potential to inadvertently impact negatively on segments of the population or vulnerable groups, and widen inequalities. The greatest health gains are achieved when those individuals that are sedentary become more active.
24. The need to set out a universal approach while recognising the needs of different population subgroups has been made explicit by the fact that significant equity and equality issues exist in respect of participation in sports and physical activity amongst children and young people. Policy that recognises these variations and is informed by understanding of their determinants is crucial to addressing health inequalities. There are often no clear objectives and activities in policy suggesting commitment of additional resources in favour of specific population subgroups.
25. The focus of policy should be less on the whole-population vs. subpopulation debate and more on the balance of ‘agency’ and ‘structure’. In this regard, there are lessons to be learnt from emerging published evidence assessing the potential effect of risk factor reductions on socio economic inequalities in health. McLaren[xiv] make a distinction between “agentic” prevention strategies (which rely solely on individuals making and sustaining behaviour change) and “structural” strategies (which work through changes in the wider social environment. There is evidence to suggest that addressing risk factors using “structural” whole-population approaches generally reduces social inequalities but an approach that focuses on high-risk individuals (“agentic” strategies) might increase the inequalities gap. Therefore, irrespective of whether policy focuses on whole population or sub-populations, its instruments need to weigh more heavily on the structural rather than the ‘agentic’.
26. Finally, the physical activity agenda is cross cutting. Evidence demonstrates that action to increase physical activity will fall across Welsh Government departmental policies such as planning, transport, communities, economic, education and early years. There needs to be more engagement between Welsh Government policies, departments and organisations. We advocate that all policies undertake a health impact assessment, as required in the Public Health Act (Wales) 2017, to understand and mitigate unintended outcomes on health inequalities.
4. Barriers to increasing the levels of physical activity among children in Wales, and examples of good practice in achieving increases in physical activity, and in engagement with hard to reach groups, within Wales, the UK and internationally.
27. There are a number of barriers to increasing the levels of physical activity. There is a need to better communicate the concept of physical activity to make it more accessible, achievable and enjoyable.
28. The barriers to physical activity in adults in Wales appear to be well understood but the same cannot be said about barriers in children and young people. Evidence from international and UK research suggests that the factors that determine attitudes to and actual participation in physical activity and sports are broadly:
· Biological (e.g. age, obesity);
· Psychological (e.g. perceived competence, believing in importance of exercise);
· Social (e.g. peers, friends exercising, trying to lose weight); and
· Environmental (e.g. type of activity, involvement in sports teams).
29. Two of the most comprehensive, if somewhat dated, systematic reviews of primary studies evaluating the perspectives of children on the barriers and facilitators of participation in physical activity were largely based on studies from outside Wales. Brunton (2003)[xv] and Rees (2006)[xvi] both synthesised primary research on children’s views on physical activity and integrated those with findings from effectiveness studies. Children’s reported barriers to taking part in physical activity clustered into three distinct categories:
· Preferences and priorities (e.g. preference for doing other things, a lack of spare time);
· Family life and parental support (e.g. parents’ lack of current participation in, or enthusiasm for, sports and exercise); and
· Restricted access to opportunities for participation in sports or exercise (e.g. cost, distance, lack of means for safe travel, lack of facilities).
30. The same studies found that the factors which children felt helped them take part in physical activity included:
· Aspects of physical activity that children value (e.g. physical activity as a means to having fun and spending time with friends, belonging to a team, competitiveness and sense of achievement);
· Family life and parental support (e.g. a supportive, encouraging and inspiring family, practical parental support). To emphasise the role of parental support, the Young People’s Participation in Sport report by Sports Council Wales found that parental involvement was established as an important influence on physical activity levels; and
· Greater access to opportunities for participating in physical activity (e.g. owning a car, access to a garden).
31. Some of the studies in those reviews addressed ways of facilitating participation in physical activity and found that the majority of the young people's suggestions was about increasing practical and material resources such as: creating more cycle lanes, making activities more affordable, increasing access to clubs for dancing and provision of single sex physical activities in youth clubs alongside or followed by mixed sex (non-physical) activities (combining sports and leisure facilities). Young people emphasised the fun and social aspects of physical activity and young women's ideas reflected a desire for more equal opportunities. Nationally the Daily Mile[xvii] is a positive example of increasing physical activity levels in a fun and achievable way within the school setting.
32. The Sports Council for Wales provides a summary of barriers to increasing physical activity categorised as behavioural/demand issues and environmental/supply issues.
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Behavioural/demand issues |
Environmental/supply issues |
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Time/commitment |
Facilities |
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Culture |
Costs |
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Gender |
Programming |
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Alternative activities |
Transport |
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PE and school sport |
Coaches quality/quantity |
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Personal appearance |
Lack of volunteers |
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Role models |
Legal concerns |
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Family responsibilities |
Competition structures |
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Parental attitudes |
Financial support |
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Personal safety/abuse |
Negative experiences |
33. Bevan Foundation Policy Paper “Active Lives: Physical Activity in Disadvantaged Communities”,[xviii] provides recommendations for increasing physical activity with hard to reach populations. The recommendations are as follows;
- Effective marketing and promotion;
- The natural environment as a resource for active living;
- Identify a national recreation;
- Walking for young people;
- Greater understanding of behavior change;
- Routine health screening;
- Evaluation and sharing of good practice;
- Establishing long term funding arrangements;
- Combating crime and anti-social behaviour;
- Providing childcare and support to establish family routines;
- Collaboration of transport arrangements;
- Tailored interventions for those at particular risk of exclusion;
- Provision of sufficient trained exercise professionals;
- Greater involvement of primary care;
- Raise the professional standing of exercise professionals;
- Breaking down social stereotypes; and
- Establish a physical activity task force.
34. Further exploration into the barriers to physical activity for children and young people and sub-groups within this population would be beneficial.We suggest that a full literature review is undertaken to inform the Committee and that a framework or theoretical model (such as COM-B),[xix] which is advocated in NICE guidance,[xx][xxi] is used to explore the relationships between barriers, to understand more fully the inter related components that contribute to positive behaviour change.
35. In order to identify examples of good practice within Wales we recommend that programmes are routinely evaluated and the findings are widely shared using a vehicle such as Public Health Network Cymru.[xxii] There is much learning that can be taken from programmes such as Communities First, Mentro Allan and Us Girls.
5. Physical activity guidelines and how we benchmark physical fitness in children.
36. The guidelines for physical activity in children and young people up to the age of 18 are very clear and consistent with international and World Health Organisation evidence-based guidelines.
37. The guidelines generally stipulate that world children engage in 60 minutes daily moderate-to-vigorous physical activity (MVPA). While the guidelines generally are consistent across countries, there is a question of whether the effect of compliance with the guidelines, for example on cardiovascular risk in children, has sufficiently been empirically tested in longitudinal studies. Indeed, recent research from Liverpool found that achievement of current guidelines has positive effects on body composition and cardio-respiratory fitness, but not on composite cardiovascular risk.[xxiii]
38. The UK Chief Medical Officers’ physical activity guidelines[xxiv] clearly show that the role of physical activity is important throughout the life course. The Chief Medical Officer physical activity guidelines for early years (under 5s) states that:
- Physical activity should be encouraged from birth, particularly through floor-based play and water-based activities in safe environments.
- Children of pre-school age who are capable of walking unaided should be physically active daily for at least 180 minutes (3 hours), spread throughout the day.
- All under 5s should minimise the amount of time spent being sedentary (being restrained or sitting) for extended periods (except time spent sleeping).
39. The UK Chief Medical Officer physical activity guidelines for children and young people (5 -18 years) states that:
- All children and young people should engage in moderate to vigorous intensity physical activity for at least 60 minutes and up to several hours every day.
- Vigorous intensity activities, including those that strengthen muscle and bone, should be incorporated at least three days a week.
- All children and young people should minimise the amount of time spent being sedentary (sitting) for extended periods.
40. UK Active Kids “Generation Inactive - an analysis of the UK's childhood inactivity epidemic and tangible solutions to get children moving” report[xxv] provides definitions and indicators of physical fitness which includes:
- The ability to carry out tasks without undue fatigue;
- Involves skill and health related elements of which cardiorespiratory fitness (CRF) and muscular fitness are important indicators of health in young people;
- Is not simply about being able to run a long way, run quickly or lift heavy weights but that flexibility and agility are important elements of physical literacy and movement;
- Fundamental motor skills, physical fitness, physical activity and knowledge are interrelated to one another.
41. The report goes on to state that a change in habitual physical activity will almost certainly lead to appreciable changes in fitness and therefore capturing children’s fitness levels before and after any intervention may enable us to understand better the effectiveness of physical activity initiatives and the quality and quantity of physical education in schools. It recommends measuring fitness levels as part of the National Child Measurement Programme in a way that is fun and engaging for young people.
42. There isn’t consensus on whether physical activity limits physical fitness, or whether physical fitness determines participation in physical activity. We do know that physical fitness in children (which can be assessed with standardized tests) is a function of both physical activity and non-modifiable factors such as genetics even if the relative role of either determinant is not firmly established. Furthermore, there is public health consensus that physical fitness is a more accurate predictor of overall health outcomes than physical activity. Given these facts, it is worthwhile to explore how physical fitness might be benchmarked alongside physical activity in children.
43. During the early years and for children there is a focus on physical and emotional development. However there needs to be much better links to mental and emotional health and well-being; happy children are much more likely to engage in physical activity and be less withdrawn and isolated. Clinicians, school-based professionals, policy makers and parents should encourage physical activity in children, not only for the physical health benefits, but for the positive mental health outcomes as well.[xxvi]
44. The guidelines for the age group ‘children and young people’ need to be more holistic and more in line with the physical activity guidelines for the ‘early years’.[xxvii] Helping parents, children and young people to see how they can make their day physically active e.g. the ‘every movement counts’ concept. Whilst these guidelines are available, their awareness could be improved. The local insight with health professionals and organisations that work with children, young people and families have highlighted that more can be done to raise awareness of physical activity guidelines for the early years. In line with national policy development, we would advocate a national communication strategy that targets the general population, segmented groups, health professionals and organisations.
45. Guidelines do not themselves change behaviour. Communication and awareness raising needs to be matched with concerted and committed action to create supportive environments, and enabling policies that make it easier for people to be more active and less sedentary.
6. Measurement, evaluation and effectiveness of the Welsh Government’s programmes and schemes aimed at promoting physical activity of children.
46. The Transforming Health Improvement in Wales Programme (2015)[xxviii] identified seven potential areas for action to increase the intensity and duration of physical activity in children and young people aged 3 to 18 years. Three of the areas of action were considered to have a sufficiently robust evidence base for implementation and the other four would require varying degrees of research and evaluation.
47. However, we are unable to comment on the effectiveness of the Welsh Government Programmes aimed at promoting physical activity of children as we have not seen evaluation data. It is suggested that the Welsh Government Programmes should ensure that work aimed at promoting physical activity is outcome focused, reduce inequalities, be informed by the latest evidence and contributes to the evidence base and adopts all of the principles of prudent health care.
48. In order to monitor the progress, a system of qualitative and quantitative data collection, analysis and feedback against a set of national indicators for physical activity should be put in place. Indicators in line with those being used internationally would allow Wales to benchmark against other UK and EU nations, and would need to reflect measurement of outcomes and progress towards outcomes. Equally qualitative approaches to evaluation and effectiveness are needed to demonstrate the differences interventions are making to people’s lives.
49. Also, adapting and flexing schemes over time to suit need and demand. Programmes and schemes are often introduced with extensive funding and support which diminish over time or the programmes become out-of-date and often don’t appear to be re-visited to make them more current.
7. Value for money of Welsh Government spending to promote exercise in children.
50. We do not feel able to comment on the value for money of Welsh Government spending, however the Public Health Wales NHS Trust publication “Making a Difference: Investing in Sustainable Health and Well-being for the People of Wales”[xxix] suggested that “Best buys’ to increase physical activity include mass media campaigns, supporting active travel (walking and cycling), brief intervention for physical activity in primary care and promoting physical activity in workplace, schools and communities”.
51. International evidence on cost-effectiveness of physical activity programmes suggest that the least cost-effective programmes are high-intensity “individually-adapted behavior change” and “social support” programs, while the most cost-effective are point-of-decision prompts (e.g. signs to prompt stair use).
52. A Canadian report[xxx] has identified the seven best investments that work for physical activity includes:
· ‘Whole of school’ programmes;
· Transport policies and systems that prioritise walking, cycling and public transport;
· Urban design regulations and infrastructure that provide for equitable and safe access for recreational physical activity, and recreational and transport-related walking and cycling across the life-course;
· Physical activity and non-communicable disease prevention integrated into primary health care systems;
· Public education, including mass media to raise awareness and change social norms on physical activity;
· Community-wide programmes involving multiple settings and sectors and that mobilise and integrate community engagement and resources; and
· Sports systems and programmes that promote ‘sport for all’ and encourage.
53. “Steps to Solving Inactivity” by UKActive[xxxi] identifies gaps in the evidence between laboratory-based research studies that have proved the effectiveness of physical activity in controlled environments and the real-world delivery of physical activity interventions. Across the public sector there continues to be a speculative reliance on self-reporting of physical activity, use of crude outcome measures such as body weight and a general absence of clinically relevant data being captured to prove public health impact. This is a matter that is inhibiting the scalability and wider commissioning of physical activity programmes. It appears to be the case when compared to other public health interventions that are better evidenced and more widely invested in such as smoking cessation programmes. There is a need for further research on the effectiveness of physical activity interventions and the economic assessment of these interventions if effective.
8. The role of schools, parents and peers in encouraging physical activity, and the role of Sport Wales, NHS Wales and Public Health Wales in improving levels of physical activity.
54. The evidence from the Public Health Wales NHS Trust “Transforming Health Improvement Report”[xxxii] indicates the interventions that work are multi-component in nature and as a result will require partnership working and collaboration. Such a vehicle to drive change at the strategic level locally will be through the Public Service Boards, where partners have an important role to shape and create enabling and supporting environments for physical activity.
55. We agree with the statement in Getting Wales Moving[xxxiii] that ‘no single agency in Wales can deliver the large scale increases in physical activity that are urgently needed in Wales’. Getting Wales Moving identifies actions to increase physical activity participation through the creation of Active Places and Active People. Within each of these areas for action there are specific actions for schools as a setting (Active Education) which includes:
· Ensuring all schools provide access to and opportunities for 120 minutes of high-quality, comprehensive physical education per week, embedding the physical literacy framework within their delivery;
· Seek out and implement practical ways to increase use of school and FE facilities during evenings, weekends and holidays;
· Assess the provision of good quality physical education lessons and opportunities in all Welsh school and utilise the physical literacy framework and school sport survey to demonstrate the impact of these being part of the Estyn Well-being Assessment framework;
· Fully implement and maximise the Healthy Schools Programme to drive co-ordinate action to increase physical activity in schools;
· Incorporate knowledge and understanding of physical activity across all initial teacher training;
· Pilot and evaluate a Daily Mile programme in a range of Welsh Schools; and
· As part of the Welsh Network of Healthy School Schemes require schools to regularly monitor travel to school; set goals for improvement and monitor change.
56. Physical activity levels of young children and families cannot be seen in isolation from wider parenting approaches so there is the need to consider the whole family when designing policies and interventions to enable daily physical activity. Targeting the factors that parents and children believe to be important may enhance intervention tailoring.[xxxiv] The role of schools, parents, children and peers is also crucial during evaluative thinking processes e.g. to provide consistent, robust and honest feedback on programmes and schemes to increase physical activity. Support for parents should include maximising each contact between early years’ practitioners and healthcare professionals to influence parents about the importance of early movement opportunities.
57. There are also clear actions for Public Service Boards, and Local Authorities in particularly, in relation to the physical and natural environment and the action required to create communities and spaces that will encourage and enhance physical activity participation. These include:
· Revised planning criteria that allows new regeneration and housing projects to consider the impact of their design on physical activity;
· The use of Health Impact Assessment; and
· Evidence –based best practice examples demonstrating how planners, transport planner, developers, planning committee members can contribute to the physical activity agenda.
58. With pressures on the system it is important to ensure that decisions do not result in the unintended consequence of undermining the efforts to improve physical activity levels. We advocate that all policies and programmes undertake a health impact assessment, as advocated by the Public Health Act (Wales) 2017.
Conclusion
59. The cross-cutting nature of the physical activity agenda means that successful delivery of any large-scale change in physical activity levels to improve population health and well-being are heavily dependent on the Government and public, private and voluntary sector organisations working with each other and with the public in co-productive and more outcome focused ways, at local, regional and national levels.
60. Importantly it is about the process which underpins the delivery of this agenda and the accountability for the changes needed which will require leadership, co-ordination, joint planning and performance management. In addition it will require public bodies to act and think differently in line with the vision and principles of the Well-Being and Future Generations Act 2015.