**1. Introduction**

Non-communicable diseases are responsible for almost three quarters of global deaths [1], and a lack of physical activity (PA) is one of their major risk factors [2,3]. Lee et al. [4] estimated that 6% of the burden of coronary heart diseases, 7% of type 2 diabetes, 10% of breast cancers, and 10% of colon cancers are caused by an inactive lifestyle. He also estimated that with a 25% increase in global PA level, more than 1.3 million deaths could be averted each year. Therefore, regular PA is an effective prevention strategy against numerous chronic diseases and may reduce their risk by 20–30% [5]. Despite the empirical evidence on the health benefits of PA [4,6], over a quarter of the world's adult population and more than three quarters of the world's adolescents do not adhere to current PA

**Citation:** Romanowska, A.; Morawiak, A.; Woods, C.; Kelly, L.; Volf, K.; Gelius, P.; Messing, S.; Forberger, S.; Lakerveld, J.; Den Braver, N.R.; et al. Health Enhancing Physical Activity Policies in Poland: Findings from the HEPA PAT Survey. *IJERPH* **2022**, *19*, 7284. https://doi.org/10.3390/ ijerph19127284

Academic Editors: Paul B. Tchounwou and Hugo Olmedillas

Received: 22 April 2022 Accepted: 9 June 2022 Published: 14 June 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

guidelines [7]. In addition, no improvement has been noticed in global PA levels since 2001 [7]. For this reason, promotion of PA is a topic of grea<sup>t</sup> importance for both the World Health Organization (WHO) and the European Union (EU) [8,9].

Since 1995, the WHO has been providing evidence-based recommendations for PA [10]. The newest were published in 2020 [11]. The document provides details on the amount, type, and frequency of PA that is needed for health and well-being for specific population groups, such as small children, school-aged children, adults, the elderly, or pregnan<sup>t</sup> women. According to Oja and Titze [10], PA recommendations targeting individuals are insufficient to achieve desired PA levels across the population, however, they may provide foundations for actions to improve the situation and metrics for their monitoring. Thus, policies to promote PA may be used as a response to the global physical inactivity problem. Compared to individual-level interventions, policies are targeted at a broader audience, community, or population, and therefore, have a wider spectrum of influence [12]. Sallis et al. [13] define PA-related policies as 'legislative, regulatory, or policy-making actions that have the potential to affect physical activity'. They may provide opportunities for increasing PA levels, provide funding for PA promotion, regulate the amount of obligatory sports at school, and coordinate activities undertaken at national or regional level [12,14]. Many studies provide evidence for the effectiveness of policies to promote PA [15–18]. Such policies have been successfully implemented in the areas of education, health, sport, urban design, or transportation. Taking the latter as an example, Brockman and Fox [19] assessed the impact of transport-related policies introduced in Bristol in 1997–2007 that included increasing parking fees, subsidies for bicycle purchases, introducing a car-sharing system, and public transport discounts, concluding that walking to work increased by 11%. Another policy introduced in Cambridge, which focused on increasing access to walking/cycling routes and places for PA, has significantly increased children's PA levels [20].

According to the WHO [21], the central role in promoting healthy lifestyles and creating an environment that encourage behavior changes belongs to the governments. The role is not limited to the health sector but also to other sectors such as transport, education, sports, or the environment. National governments have a steering and coordinating role in implementing strategies and meeting recommendations developed by WHO [21,22] or EU [8] at the national level. They have resources to provide effective legislations, develop programs, and ensure an appropriate infrastructure, funding, monitoring, or research opportunities. National policy is an important platform for governments to develop, coordinate and deliver large scale actions across multiple sectors, involve stakeholders, assign roles and responsibilities, define common objectives and gain visibility at the political level [23]. However, not all countries use the potential their governments have in PA promotion.

To assess the national PA policy potential and approaches, the WHO proposed a policy audit tool (Health-Enhancing Physical Activity Policy Audit Tool—HEPA PAT) and a wide variety of countries have used it so far [24–27]. The HEPA PAT is a standardized questionnaire designed to collect comprehensive, systematic, and comparable data on the approaches to PA promotion at the national policy level [23,28]. The completed HEPA PAT questionnaire provides a comprehensive overview on the current status of a country's approach to enhancing PA, allows to identify strengths and weaknesses of the current national policy approach, indicates synergies and discrepancies between national level policy documents, and identifies whether there is enough communication and collaboration between sectors [23]. Finally, it allows for country comparisons [23,24], communication of good practices, and success stories to be used by other countries.

This paper presents the results of a comprehensive assessment of national-level PA policy approach in Poland based on the data systematically collected with the use of HEPA PAT questionnaire. The paper aims to answer the following questions: What are the strengths and weaknesses of the Polish PA policy approach? What policy areas need to be improved? The findings from this study will contribute to advanced knowledge in this particular area and to help policymakers and practitioners design and plan actions

to increase PA levels among the whole of society. The rationale for this study is aligned with the work of the Policy Evaluation Network (PEN; https://www.jpi-pen.eu/). PEN aims to develop a consolidated approach to policy evaluation across Europe by developing and prioritizing an agreed set of indicators, measured using harmonized instruments that ideally can be used by existing monitoring and surveillance systems [29]. This study was also the first step in developing the prototype of 'Physical Activity Environment Policy Index', a tool that can be used to independently monitor and benchmark public sector PA policies and actions.

#### **2. Materials and Methods**

To identify and assess the current state of the national-level PA policy approach in Poland, the WHO's audit tool HEPA PAT version 2.0 was used [28]. The questionnaire consists of 29 questions in 10 subject areas (Table 1). The process of completing the HEPA PAT was supervised by the project coordinator (JZ) and involved national stakeholders ˙ from several sectors such as sports, health, education, and transport.

**Table 1.** The overview of the HEPA PAT structure.


The process of data collection started in March 2019 and was completed in July 2019. It consisted of the following stages: (i) identification of stakeholders; (ii) collecting the data from the 2018 survey for the EU Monitoring Framework after obtaining consent from the national PA Focal Point and the WHO; (iii) desk research conducted by the authors, including the identification and the review of existing policy documents, programs, activities carried out at the national level and related to PA promotion; (iv) in-depth expert interviews to obtain additional information and input for the HEPA PAT; (v) completing the HEPA PAT questionnaire by the authors. The in-depth interviews with experts involved the representatives of the Polish Ministry of Health, the Ministry of Sport and Tourism, the Ministry of Infrastructure, and the Ministry of Education (currently the Ministry of Education and Science). The participants were selected based on their expertise in the PA policy setting and policy implementation.

Similarly, data were collected in Ireland, The Netherlands, and Germany [23,24,27]. While the results of this four-country comparison have been published elsewhere, this article presents the results for Poland in a higher level of detail.

In order to characterize the various policy aspects related to the development, implementation, monitoring, and evaluation of PA policies, a content analysis of the completed HEPA PAT questionnaire was performed. This is a research technique widely used for making inferences from analyzing documents that were generated or obtained in the course of research [30]. The HEPA PAT categories served as basic themes for the analysis. The research questions were raised to understand the information of how it is presented: How is the process (e.g., implementation, evaluation) organized? What are the outcomes? What lacks in the process? The conclusions were drawn from the HEPA PAT content to the context, which is the history and current state of PA policy approach in Poland, using the experience and knowledge by researchers directly involved in the data collection process.

To summarize the results, a SWOT (strengths, weaknesses, opportunities, threats) analysis was used. This is a powerful tool widely used in strategic planning and management, which is helpful to appraise the state of the art and accommodate organizational and environmental factors that influence the current situation [31]. SWOT analyses have been adopted in some qualitative studies to evaluate policy approaches in recent years, including energy planning strategies [32,33], the compressed natural gas industry, [34] or urban transport system [35]. It has also been applied to evaluate PA promotion in a household group survey [36]. In this paper, SWOT is used to structure the factors influencing and shaping PA promotion policy at the national level in Poland. For this purpose, the particular components of SWOT representing internal (strengths and weaknesses) and external (opportunities and threats) factors, respectively, were summarized in a 2 × 2 matrix. The matrix components were further divided into rows comprising factors in accordance with the adopted themes and matching them horizontally (i.e., strengths with corresponding weaknesses; opportunities with corresponding threats).

## **3. Results**

#### *3.1. Leadership and Partnership*

Poland is a unitary state with a strong central government. In line with the EU recommendations on promoting health-enhancing PA (HEPA) across sectors [8], Poland has appointed a National PA Focal Point at the Ministry of Sport and Tourism, Department of Sport. The Ministry is responsible for the development and implementation of national sport and tourism strategies. It undertakes many activities to promote PA, but these are limited mainly to the area of sport. The Ministry does not provide any leadership and any umbrella for PA promotion activities implemented in other areas (i.e., health, transportation, and social policy).

Apart from the Ministry of Sport and Tourism, other governmen<sup>t</sup> ministries have their own role in PA promotion. Table 2 presents information about ministries, their responsibilities, and how they are related to PA promotion. The Ministry of Health, responsible for health policy, develops and implements the national health strategy, which covers

PA-related tasks. The Ministry of Family and Social Policy, responsible for the welfare of Polish families and the whole society, supports the development of care services and cares for the PA of seniors. The Ministry of Education and Science, responsible for teaching and education, supports the development of educational programs, including physical education (PE) classes at schools. Although the Ministry of Infrastructure, the Ministry of Investment and Development, and the Ministry of the Environment do not have special roles in PA promotion, they indirectly support PA by different programs devoted to active transport, active mobility, and development of green transport.


**Table 2.** The role of Polish ministries in PA promotion.

There are currently no special mechanisms or agencies to ensure the co-operation between particular ministries in the implementation of the PA policies at the national level. There is also no agency at the national level to promote and coordinate PA activities with the subnational level, either horizontally or vertically.

#### *3.2. Policy Documents*

The most important policy documents that influenced the shaping of the PA policy agenda in Poland were the National Health Programme 2007–2015 [37], the Sport Development Strategy until 2015 [38], and the Directions of Tourism Development until 2015 [39]. These programs covered the sectors of sport, health, education, and tourism. All were continued and covered the period until 2020 [39–41]. In addition to the mentioned programs, there are policy documents in other sectors that have implications for PA behavior; these are the Transport Development Strategy until 2020 [42] which appeared in transport sector, and the National Urban Policy 2023 [43], which is rooted in the urban planning sector. Key policy documents related to PA promotion are listed in Table 3.

While there are a number of current key policy documents expressing the intention to increase the national level of PA (e.g., [39–41,44]), there are no clear references across these documents and links to other documents. The only existing links refer to policies at the European level. An example is the Sport Development Programme 2020 [41], which takes the European Commission's White Paper on Sport [45] as a basic document setting strategic guidelines for the role of sport in Europe and Poland.


**Table 3.** Key PA policy documents in Poland.

*3.3. Policy Scope and Implementation*

Nearly all population groups, including preschool children, adolescents, individuals with disabilities, clinical populations, families, and migrant populations, are covered in the documents identified.

Although there is no nationwide mass media communication strategy to promote PA in Poland, some agencies are funding initiatives that utilize mass media, i.e., social media channels. However, no coordination of these initiatives is ensured.

On the other hand, there are many successful programs and interventions in Poland promoting PA in sectors such as health, sport, education, transport, and environment. The most successful and widespread programs in recent years were the National Talent Base, the Local Sports Animator, the Orlik 2012, and the Stop Abstention from PE Classes (Table 4).

**Table 4.** Selected PA-related programs and interventions implemented in Poland.


#### *3.4. PA Recommendations, Goals and Targets*

Poland has official guidelines for recommended levels of PA in different age groups, including children of all ages, adults, and seniors [46]. In case of adults, the recommendations are also targeted to pregnan<sup>t</sup> women and adults with chronic diseases, but not to people with disabilities. The document is based on the WHO recommendations and considers the results of the study on PA among Poles conducted in the years 2015–2017. The recommendations set minimum and optimal time of weekly PA recommended in particular groups and propose the type and intensity of activity that should be undertaken, i.e., for seniors, it is recommended to undertake 150 min of moderate PA per week, including exercises to improve balance, coordination, and to strengthen all body muscles.

Sedentary behavior is not addressed by any national recommendations. This is an important weakness of the Polish PA promotion system, while many countries provide recommendations in this regard (i.e., Estonia, Greece, and France) [47].

Improving the PA levels in Poland was the main goal of the Sport Development Programme 2020 [41]. According to the program, the percentage of residents that undertake the recommended amount of PA was to be increased by 3.5% and the percentage of residents that never do exercise or play sport was to be lined up with the EU average. Mid-term evaluation indicates that even though the situation has improved, Poland is still far away from achieving these goals [48].

## *3.5. Surveillance*

Poland has been conducting regular PA monitoring among different age groups for the past ten years. In 2016, the country joined the WHO's European Childhood Obesity Surveillance Initiative (COSI) [49]. Within the initiative and financed by the National Health Programme [40], a standardized survey and body measurements were conducted among 8-year-olds in 2016 and 2018. The results of the study provide information on the level of PA and sedentary behavior of school pupils. According to the latest results, a large proportion (61%) of children do 1–2 h of PA daily, however there is also a significant proportion (10–20% depending on the type of day) who are not active at all. The time spent on watching TV or using electronic media is approximately 1.5 h on an average school day and 2.5 h during non-school days.

Since 2010, Poland has been carrying out the regular monitoring of PA among children aged 11–15 using the HBSC methodology [50]. The studies were conducted in 2010, 2014, and 2018. The latest study [51] showed that the recommended PA level in Poland is achieved only by 17.2% of teenagers. Most of the teenagers (approx. 60% during working days and 80% during weekend) spend more than two hours a day sitting in front of TV, computer, tablet, or smartphone, and this percentage is increasing.

Pilot studies are also carried out in other age groups, e.g., among older youth (17–19) and in pre-school children. The health and PA level among Polish residents have also been a subject of a study based on the European Health Interview Survey (EHIS) [52] in 2009, 2014, and 2019. Since 2014, the Ministry of Sport and Tourism has been committing research on the PA levels of Polish residents on an annual basis, using the International Physical Activity Questionnaire (IPAQ) [53]. The aim of the study is to indicate the percentage of Polish residents meeting the WHO's recommendations regarding the time spent on PA (according to the latest results these are met by only 21.8% of residents aged 15–69 [54]).

A regular monitoring of PA is also provided by the Main Statistical Office (2008, 2012, and 2016), using a questionnaire survey in households. The respondents are asked about their perceived physical fitness and the level and regularity of PA.

Despite the amount of data collected and updated in the above-mentioned studies, most policy documents do not take the results into account. The exception is the National Sport Development Programme 2020 [41], whose goals were based on the diagnosis using surveillance data, as well as the data used for program monitoring. The existing data are also not commonly used for PA promotion activities. However, some good practices can be found. In 2009–2012, the National Supreme Audit Office has investigated the organization of PE classes and the levels of participation. The results were alarming—physical fitness among children decreased, they often had bad posture, and they experienced the fastest weight increase in Europe. The PE classes were also neglected by schools and teachers; according to the results, 65% of the classes were not even conducted. In response, the Ministry of Sport and Tourism has initiated the promotional campaign Stop Abstention from PE classes (Table 4), which aimed to fight against the scourge of PE exemptions and increasing parents' awareness about the importance of PA for children's health and fitness.
