Physical Activity Policy and Program Development: the

Experience of Finland

Ilkka Vuori, MD, PhD, professor (emeritus), Tampere, Finland,ilkka.vuori@uta.fi

”Sport and Health Policies”, 2nd International Sport Countries Conference

Barcelona, November 24 - 27 2008

Foundation for Sport and Health Policies

Very strong scientific evidence shows the great potential of physical activity for health, www.health.gov/PAGuidelines

Well known fact to us, but not so well knownto, or internalized and accepted by policyand decission makers at various levels

Strong advocacy (agitation) is needed!The experience of others may be useful

Regarding health, PA is• for individuals: ”a health insurance”

decreasing the risks and increasing the capacity to bear the consequences of the materialized risks

• for societies: an investment for betterhealth, lighter burden and smaller costs of diseases and infirmity.The individual health benefits of PA accrued during the whole life span are collectively seen in the population´shealth.

But the qualities of PA´smake a difference regarding

its effects on health!

Health-Enhancing Physical Activity(HEPA) (Vuori 1990)

Any physical activity that regardless of its reasons(motivations) has been shown to produce effectsthat enhance health (physical, mental, social) without undue risks or harms.

In order to meet the criteria above the activity hasto be frequent, continuous, and moderate in relation to the capacity of the person practicing

recommendations, guidelines.

Activityfor health

Exercise for fitnessActive

living

Light, moderateDailyTens of minutes, even hours

ModerateAbout dailyAt least 30 min

Moderate, vigorous3 times a weekAt least 20 min

StrenuousSeveral times a weekVariable

Trainingfor sport

Type and amount of activity

Health,fitnessbenefits

Risksand

harm

s

BenefitsBenefits

Risksand

harm

s

Vuori / UKK Institute 1

Because of the great values of PA

• it is decleared to be the right of everyone”Sports for All” ~ ”PA for All”

• opportunities for PA should be availableto everyone.

Systematic promotion of PAis a task of the society

Successful promotion of PA in a population is a very demanding task

because• large number of insufficiently active people• many factors (determinants) influence in

favour of and against change of an individual´s physical activity

Physical Activity: determinants

• social• professional• economical

• sites and services:availableaccessibleaffordableacceptableappropriate

• time

• skills• health

• emotional:experiencesexpectations

• rational:knowledge

• norms and values

SupportOpportunitiesAbilitiesWillingness

Successful PA promotion requiressystematic use of multiple large-scale, long-

standing measures in co-ordinated fashionthat address the critical determinants.

Planning, funding, and implementation of these kind of measures calls for acceptanceof PA promotion as an important goal at the state or community level, and for agreementof the directions to reach the goal, i.e. policies.

What policies are needed?

Sport, recreationYouth, elderly, genderEducation, schoolHealthUrban planningBuilding, constructionTransportSafety, consumer

InsuranceResearchMedia

Sites, servicesEqual opportunitiesEducation, instructionInformation, counselingAccessible opportunitiesAccessible, appropriate -”-Safe, accessible opportunitiesSafe, appropriate equipment,

services, sitesIncentives, safetyEvidence, guidelinesInformation, attention,

boostering, advocacy?

Examples Especially for

© Ilkka Vuor

In health, Finland advocates”Health in all policies”Should we advocate”PA in all policies”!

PoliciesSport, recreationYouth, elderly, genderEducation, schoolInformation, mediaHealth, insuranceUrban planningBuilding, constructionTransportSafety, consumerResearch

Willingness Abilities Opportunities

More Movement

Actions, programmes

Elements of Effective PA Promotion

© Ilkka Vuori, 2001

What have the Finnish policy and decission makers done to make

”PA for All” a reality?

How well have they succeededin making Finns physically

active?

19801980 -90-90 -91-91 -92-92 -93-93 -94-94 -95-95 -96-96 -97-97 -98-98 -99-99 20002000

HEPA in FinlandHEPA in Finland

Z

Finland on the MoveFinland on the Move FIT FOR LIFE IFIT FOR LIFE I FIT FOR LIFE IIFIT FOR LIFE II

UKKInstitute

SportsCommittee

”Social Justificationfor PA and

Sport” I

New sportfundingpolicy

NationalHEPA

coalition

HEPA for young

Finns

NewSports

Act

Recommendationsfor local HEPA

promotion

NationalHEPA

Committee”Social

Justificationfor PA and

Sport” II

First Sport Act (1979)• Significance: strongest policy, legal positioning and

”protection” of PA, important especially during ”difficulttimes (economic crisis etc.)

• Grounds: social functions of sports, e.g. health• Division of duties

– Responsibility of the state and the municipalities:establishment of sites and basic services on equal basisto all

– Responsibility of voluntary organizations: arrangement of leisure time physical activities

– The state supports financially the municipalities and sports organizations.

– In addition, the state supports sports-related research.

Sport Act 1999Purpose: to advance physical activity and sports and

related civic activity, to enhance population health and well-being through sports, and to support young peoples´ growth and development

• Division of responsibilities: mainly as in the first sport act

• The municipalities have the responsibility to create opportunities for health-enhancing physical activities by developing local and regional collaboration, by supporting civic activity, and by offering sites and services, also considering people with disabilities.

Government programsStates the directions of a new government,

(State Council) strongly binding policydocuments

Former government´s program: State fundswill be directed to sport of children and young people that enhances health and emphasizes educational and ethical aspects.

• Enhancement of health and functionalcapacity of adults, elderly, and peolple withdisabilities through sport will be supported.

Current government´s programSport policy will be used to enhance

well-being, health, and functionalcapacity of the population.

Action lines and measures will bedefined in the National Program for Sports and Physical Activitygovernment resolution (with emphasison public administration)

1st Government Resolution on Health-Enhancing Physical Activity (2002)

• Expresses the commitment of allministries in the Finnish government to promote physical activity for health, and the ministries are responsible for developingmeasures increasing and improvingconditions for health-enhancing physicalactivity in their own sectors.

• Many measures directed to increasephysical activity explicitly for health

1st Government Resolution on Health-Enhancing Physical Activity

• Principles included:– Collaboration among government sectors– Consideration of PA in land use, environmental

planning, community structure, and everydaysettings

– Inclusion of PA as an explicit part of municipalwellness policy

– Increased research and education related to health-enhancing physical activity

• Also funds: 2 million euros in 2003, more in 2004

2nd Government Resolution on Health-Enhancing Physical Activity (2008)

• Also diet included• Sites and services for HEPA belong to the basic

municipal services, to be included in the planningand evaluation

• All age groups addressed• Physically active commuting to be stimulated• Opportunities especially for balance and strength

training for the elderly• Emphasis on environments enabling and

stimulating for HEPA• Counseling for HEPA to be increased

Transport policyIncrease of walking and cycling in transport

(partly for health): series of policies and programs since 1992, the By Foot ongoing.

Evaluations mainly positive demonstrating the need of longstanding cooperation of multiplepartners in research, development, demonstration, and implementation of numerous simultaneous and successivemeasures to reach the goals

Implementation of policies: major programs and

measures

ProgramsTwo national HEPA programs since 1991: • Finland on the Move 1991 – 1994• Fit for Life 1 1995 – 1999• Fit for Life 2 2000 – 2004• Fit for Life 3 2005 – 2009• Fit fort Life 4 2010 -2014, decidedLargely the same basic ideas and principles,

gradual enlargement in aims,size, targetpopulation, and number of partners

Fit for Life:aims(gradually developed)

• To activate insufficiently active individuals• To develop models for producing high-quality

and sustainable HEPA services at local levelthrough co-operation

• To create networks of HEPA actors• To get transport and environmental sectors

involved

Fit for Life: Principles• free access• local ideas (new, innovative)• networking• targeting insufficiently active people• sustainable changes• financial support based on competition• supporting independent activity

Criteria of project competitionTarget: large number of middle-aged people

Good idea • to reach the non-exercising people• to motivate them to begin exercising• to support them to continue exercising regularly

Co-operation between sport and other sectorsContinuation and resources: persons, money, facilities

Fit of Life: Means

• financial support• Information (print, audio-visual, media)• training• networking• evaluation

Projects, funds, partners• Currently more than 800 projects supported,

projects have been in nearly every municipality, only a part of them have sustained

• Currently the annual budget is 1.9 million euros, about half of this to the projects

• Partners: Ministries of Education, Social Affairsand Health, Transport, and Environment; Forestand Park Service, and for a period Social Insurance Institution, an insurance company and some commercial sponsors

Fit for Life: Some lessons learnedThe bottom-up mode innovative and effectiveNetworking effective new, also cross-sectoral

collaboration at national and local levelLight organizational structure cost-effective but

weak in strategic leadership”Seed money” for the projects key instrument but

has led to fragmented and diffuse impactPopulation impact (PA, health, function) difficult to

assess despite surveillance and evaluations

Other national programsincluding HEPA

• Finnish Heart Health Program: HEPA one of the best realized parts

• Diabetes Prevention Program: HEPA a key part

• Strength for Old Age• Movement Prescription Project• National Bone and Joint Program

Strength for Old Age Program

Aims: to increase functional capacity, autonomy and quality of life of elderly persons (75+) withdecreased functional capacity bycreating high quality, permanentservices providing strength and balance exercise programs

Measures1. 35 projects, mainly in service homes : exercise

programs epecially for strength and balance, implementation supported by education, instruction, stimulation and guidance of the instructors and the participants

2. Advocacy: nation-wide information, communication, and networking activities to influence decision makers, interest groups, and media

3. Dissemination of the products (knowledge, experience and good practices) through a national network of instructors, Web, newsletters, publications, and fairs.

Effect of exercise measured byperformancetests: blue =

improved

HANKERYHMÄ 2005Testattuja 426 henkilöä

65 %

17 %

9 %

9 %

Tulos parantunutTulos pysynyt ennallaanTulos heikentynytErisuuntaiset tulokset

80 % of the projects experienced that the guidance benefited their developmental workgreatly or very greatly; majority of the firstprojects led to permanent exercise programsin the service homes.

Preliminary results

Movement on Prescription• 4-year national project supported by the

Ministry of Social Affairs and Health, and bythe Finnish Medical Association

• The program was not effective in increasingthe frequency of asking about PA habits orthe frequency of using the prescription orother written material in PA counseling

Other implementations, examplesChange of criteria for state subsidies to

sports organizations (1995): more weightto health, fitness, and youth sportseffective in supporting HEPA (more funds, new interested partners)

Change of criteria for state subsidies for construction of sites for PA (2001):priority to sites serving ordinary people in their daily environment effective in changing emphasis.

Thus, what has been doneregarding

Physical Activity: determinants

• social• professional• economical

• sites and services:

availableaccessibleaffordableacceptableappropriate

• time

• skills• health

• emotional:experiencesexpectations

• rational:knowledge

• norms and values

SupportOpportunitiesAbilitiesWillingness

Strong policies attempting to

• address all population groups on equalbasis but emphasizing the needs

• direct resources to sites, services, and functions advancing ”PA for All”

Rather extensive measures to increase willingness of

• the politicians to advance PA byproducing, collecting, summarizing, and disseminating evidence on social significance of PA (e.g. books, campaigns in connection with national and local elections)

• the people by disseminating knowledgeand information of the value of and opportunities for PA, and by offeringopportunities for favourable experiences in and through PA

Rather extensive measures to increaseabilities = skills related to PA of

• teachers, instructors, trainers, peers etc.: to plan, organize, instruct, guide etc. ”PA for All” byproviding education and training at various levelsfrom university degree to short courses

• the people to practice PA by providing mandatoryphysical education in schools (for > 160 years!), and by using the services and activities of the municipalities and the ~ 9000 open-access sportsclubs, and of the PA programs described earlier

Rather extensive measures to increase opportunities for PA by

• developing and maintaining sites and services, e.g. ~ 30 000 built sportsfacililities (1/170 Finns), construction costssubsided by the state, 75 % owned and run by municipalities affordable to mostpeople

• financial support of the state and municipalities to the sports and other civicassociations to provide low cost services

Measures to increase support• Social support: the functions of the sports

associations; Network for Familysports; World PA Day; PA Day for the Elderly etc.

• Professional support: extensive educationand training of PA professionals; someattempts on the health sector, e.g. the PA on Prescription –project

• Financial support: low cost sites and services; PA vouchers provided by employersto employees (tax free for 200 euros/year for both parties, culture vouchers (2009 - , 400 euros/year) to subsidize costs of participation

State funding and major actions for HEPA promotion: 1990 - 2006

1999Liikuntalainuudistus

LipposenII hallitus-ohjelma

OPM:n lasten ja nuorten liikunta-ohjelma

LYP II

Finland on the Move/Min Edu

0

1

2

3

4

5

6

7

8

-90 -91 -92 -93 -94 -95 -96 -97 -98 -99 -00 -01 -02 -03 -04 -05 -06

milj. euros

FFL programme/Min EduFFL programme/Min HealthYouth pa/Min EduHEPA/Min HealthHEPA/Min EduStrength to ageing/RAY

1990Liikuntakomitea:Hyvinvointialiikunnasta –liikuntaa kaikille

1991Liikunta-Suomi-projekti

1994LYP

1995KKI

2000TELIpaikallisetsuositukset

Liikunta-paikkarak.tukea lähiliikunta-paikkoihin

KKI II

2001Terveys2015

TELIkomitea-mietintö

JALOIN-ohjelma

2002VN:nperi-aate-päätös

TELIneuv.-kunta

2003Vanhasenhallitus-ohjelma

STM:nTELI-raha

2004OPM:nTELI-raha

Voimaavanh.-ohjelma

2005KKI III

RAY:ntukiVoimaavanh.-ohjelmalle

TELIneuv.kun-nanII kausi

2006Kansall.liikunta-ohjelma alkaa

j

Initiation, planning, and implementation of the health-related PA policies and programs

Difficult to be sure of the initiation chain and of the most important actors

Agenda setting: the role of research and researchers has been important, evidence basedadvocacy, ”making the case”.

Planning: key role played by the centraladministration, esp. Ministry of Education. Mostpolicies are developed by committees representinglarge numbers of stakeholders.

Implementation: key roles played by the sport sectorof the municipalities and the state, while the health sector and traditional sports organizationshave been slower to join.

Has PA of the Finnsincreased?

Proportion of thoProportion of those among 15–64-year-olds who pursue leisure time physical activities for least 30 min at least 2 and at least 4 times a week in 1978 – 2006

se among 15–64-year-olds who pursue leisure time physical activities for least 30 min at least 2 and at least 4 times a week in 1978 – 2006

Proportion of those among 15–64-year-olds who pursue leisure time physical activities for least 30 min a 15–64-year-olds t least 2 and at least 4 times a week in 1978 – 2006 least

-78 -80 -82 -84 -86 -88 -90 -92 -94 -96 -98 -00 -02 -04 -060

20

40

60

80

100Men

0

20

40

60

80

100

-78 -80 -82 -84 -86 -88 -90 -92 -94 -96 -98 -00 -02 -04 -06

Women

Year

>2 times a week

>4 times a week

%

Year

%

>2 times a week

>4 times a week

Source: Health Behaviour and Health among Finnish Adult Population 1978 – 2006 (National Public Health Institute)

Daily walking and cycling to work among 15-64 y old women and men:1978 – 2006 (%).

0

20

40

60

80

100

-78 -80 -82 -84 -86 -88 -90 -92 -94 -96 -98 -00 -02 -04 -06

men %

year

0

20

40

60

80

100

-78 -80 -82 -84 -86 -88 -90 -92 -94 -96 -98 -00 -02 -04 -06

women%

year

>15 min per day

>30 min per day

>15 min per day

>30 min per day

Suomalaisen aikuisväestön terveyskäyttäytyminen ja terveys (AVTK) 1978 – 2006 (KTL)

Daily pa among 65-84 y old: 1997-2005

0102030405060708090

100

1997 1999 2001 2003 2005

Men, walking

Men, other pa

Women, walking

Women, other pa

%

Eläkeikäisen väestön terveyskäyttäytyminen (EVTK) 1997 – 2005 (KTL)

How do we interpret the results?Much posititive:– Increased awareness and positive attitudes

among most politicians and people proven bysurveys

– Potentially effective policies and programsand their serious implementation

– Various physical, administrative, organizational, and social infrastructures

– Victory in a ”defense battle”?: slight increasein leisure time PA but decrease in total PA; high ranking in international comparison

pation (hours per week, in %) of adults in LTPA in 15 EU countries (de Almeida et al.

Participation (hours per week, in %) of adults in LTPA in 15 EU countries (de Almeida et al. 1999).

Country None < 1.5 h 1.5 – 3.5 h > 3, 5 h % % % %

Austria 13 1 7 77 Belgium 38 2 9 50 Denmark 23 2 7 67 Finland 8 1 6 84 (1)France 35 2 9 54 Germany 30 1 8 61 Greece 40 1 6 54 Ireland 13 1 6 80 Italy 38 3 8 52 Luxembourg 18 4 10 68 Netherlands 16 1 9 73 Portugal 60 3 7 30 Spain 37 3 11 49 Sweden 10 2 5 83 UK 23 1 9 67

What has been learned? (1)Evidence-based advocacy and marketing

effective research, surveillance, evaluation, communication needed

Sustainable results call for large-scale, long-termconcerted actions by multiple partners

HEPA is or can be important issue on severalsectors and for many public and privateorganizations and institutions within and outside PA and health sectors good and increasingopportunities for collaboration

What has been learned? (2)Administration and organization at the national

level are needed to ensure sufficiently highpolitical commitment, visibility, leadership, and supporting functions.

Participation in PA takes place at the locallevel. Therefore, municipalities and localorganizations are the primary partners to besupported and strengthened.

Civic organizations are nearest to the people, and they should play key roles in carrying out the practical work

What has been learned? (3)

Key role of research: Thoroughunderstanding of the deep roots of PA behaviour is needed in order to have reliablebasis to plan effective, cost-effective, and acceptable policies and measures to increase PA. Without this knowledge, the effectiveness of the efforts will be insufficientto convince the policy makers to move for movement, and to make people to increasetheir movement.

What could be done better?To apply social marketing theories and approaches

more systematically in order* to offer right products to right people at right timesin right places for right ”price”, and * to develop effective and sustained collaborationwith multiple partners by creating ”win – win”situations.

To implement well-focused and well-plannedmeasures on even more areas, in even larger scaleand for even longer periods.

To keep in mind, that all decissions at all levels relatedto PA are after all made by persons ~ individuals(even if they are bureaucrats!) they have to bemade willing to move for movement.

Dear Friends and Colleaques

PA promotion is an important and fascinatingarea for research and practice.

It is an ultraendurance task that needs skillfuland energetic experts to cover the wholespectrum from ideology to practicalapplications.

But it is worth the effort!Take it and enjoy it, best luck!

Muchosgracias!

HEPA development in Finland

1980 1990 1991/93 1994 1995 1999 2000 2001 2002 2003 2004 2005 2006

UKK Institute

Sport Committee:PA for all

Finlandon theMove

SocialSignificanceof Sport 1

Fit for Life 1

SocialSignificance of Sport 2

Fit for Life 2

On Foot Programme

HEPA AdvisoryBoard 1

Min Health fundingforHEPA

“Strength to Aging”

HEPA Advisory Board 2

National PA programme

New Sport Act.

HEPA Committee Report

Government Resolution on HEPA

Min Edu funding for HEPA

Fit for Life 3Local HEPA Guidelines