Agenda-setting policy analysis on Iranian physical activity promotion policies: An application of Kingdon’s Multiple Streams Framework

doi:10.21203/rs.3.rs-1613271/v1

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Agenda-setting policy analysis on Iranian physical activity promotion policies: An application of Kingdon’s Multiple Streams Framework

https://doi.org/10.21203/rs.3.rs-1613271/v1

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Background: Since physical inactivity is currently a global concern, encouraging individuals to physical activity (PA) is a priority in public health policies. This study was conducted to analyse the process of change in adopting policies aimed at promoting PA in policy agenda-setting.

Methods: This qualitative study was conducted by using document review and semi-structured interviews with 23 key informants of different sections and levels of the policy-making process of the PA promotion programs in Iran. Purposive sampling with maximum variation was used to identify key informants. Analysis of documents and interviews was performed based on the Kingdon’s multiple streams Framework (MSF): problem, policy and political streams. MAXQDA-10 software was applied to manage data analysis process.

Result: The problem stream was found to be the high prevalence of physical inactivity, perceived subjective barriers, and contextual factors for PA within the country. The policy stream focused on integrating PA services into primary health care, conducting national and global calendar campaigns and events, and existing legal structures to promote PA in the community. In the political stream, the support of national documents and various legislative and governing authorities, as well as international support, especially the World Health Organization’s 2018-2030 program, provided a favourable environment for this issue.

Conclusion: Despite the opening of a policy window for policy-making to promote PA in Iran, several challenges were identified that hindered the policies; the championship and professional approach in the Ministry of Sports, lack of inter-sectoral cooperation, restrictions due to international sanctions and the Covid-19 pandemic, and managerial-structural problems. As the policy window is not used in an appropriate manner, the policymakers need to revisit the policies, with a particular attention to feasibility of the policies, the organizational culture of different Iranian ministries, and the mediating and advocating roles of the Ministry of health in operationalizing the policies.

Physical activity

policy analysis

Agenda-setting

Kingdon’s multiple streams

Inadequate PA accounts for 30% of the global burden of ischemic heart disease, 27% of diabetes, and 21-25% of colon and breast cancer (1). These diseases cause the death of more than 41 million people a year, and a third of them occur before the age of 70 (2). Despite the known benefits of PA worldwide, 31% of adults are physically inactive (3, 4)so that physical inactivity and sedentary behavior have become the biggest challenges of the 21st century (5). According to a national survey of risk factors for non-communicable diseases, the level of PA in 55% of Iranian adults was lower than the level recommended by the World Health Organization (6).

Currently, insufficient PA is a global concern; for this reason, encouraging individuals to PA is a priority in current public health policies (3). In 2013, the Global Action Plan for the Prevention and Control of Non-Communicable Diseases (2013-2020) created a commitment for countries to assess and control non-communicable diseases by targeting four key risk factors, including inadequate PA (7). In 2018, the World Health Organization outlined 20 recommended policy actions and intervention for countries as parts of “Global Physical Activity Plan.” (8)

Given the importance and economic efficiency of interventions that lead to people's participation in PA, in developed countries, various and effective programs have been implemented in coordination with all policymakers and stakeholders. In this regard, in the last three decades, Australia, Canada, the United Kingdom, and the United States have achieved significant success in reducing the cardiovascular disease mortality rate (9).

In Iran, PA in macro policies, including the Constitution (general policies of the Supreme Leader, parliamentary laws (10), and Cabinet approvals), policies of the Supreme Council of the Cultural Revolution, national programs of the Ministry of Health and Medical Education, The Ministry of Education, the Ministry of Labor Cooperation and Social Welfare, and the Ministry of Sports have been considered. In addition, a 20% reduction in the prevalence of inactivity in the population of the country is one of the goals of the National Document for the Prevention and Control of Non-Communicable Diseases in the period of 2016 to 2026 (11).

Although the importance of supportive policies in promoting PA is well known, the lack of development and poor implementation of such policies in the Middle East and North African region is still one of the biggest health challenges for these countries (12). These challenges include the lack of political commitment of governments, lack of attention to policy research, structural issues in the development process of these countries, inadequate executive capacity and lack of attention to the social, and economic and cultural contexts of such societies (12). Currently, one of the most essential needs to improve the population health is to formulate appropriate policies and implement interventions to combat the global epidemic of physical inactivity (13). However, policies to promoting PA have great potential to improve community health. It should be noted that commitment and political will, at the highest level of a government as well as the supporting policy-making by actors and elites, is not only important to put PA on the policy agenda-setting but also is critical to implementing developed policies.

Conceptual framework

One of the most widely used conceptual tools in understanding the agenda setting in the health system is MSF (14). Emphasizing the role of various stakeholders inside and outside the government, Kingdon mentioned the term "Policy windows" to discuss whether or not to include an issue on the government's agenda. By opening and closing this windows, we can add a policy to the government's agenda or hinder it from entering the agenda (15). According to this theory, the public policy process has a random feature and has three streams: problem stream, policy stream, and political stream, which work independently of each other. The problem stream includes the wide range of problems and issues that communities with them, some of which are identified as issues that need public attention. Policy stream refers to a set of policies and solutions that are debated and developed to solve national problems. This stream contains ideas and technical suggestions on how to solve problems. Political transitions, national conditions, and social pressure are also the elements of the political stream. At certain points, these streams merge and, at their intersection, policy windows allow governments to decide to put an issue on the agenda (Fig 1) (16, 17).

Study design

This qualitative study was conducted with the framework analysis approach (18) by using the MSF through document reviews and interviews with key informants. We explained affecting factors on the PA problem stream, solutions to managing low PA, and political stream.

Documents review

All available and accessible policy documents (Table 1) to promoting PA in Iranian society (national documents such as the constitutional law, five-year development plans, laws of the parliament, instructions regulations, minutes, and reports of government agencies) and articles published in reputable scientific and information databases were searched and collected.

First, we searched the published articles through scientific databases such as Google Scholar, SCOPUS, PubMed, and Scientific Information Database (SID). Second, laws, programs, minutes, and official reports were searched on the websites of relevant organizations, including Parliament, the Ministry of Health, Medical Education, and the Ministry of Sports and Youth. Third, the documents mentioned in the references of articles and official reports and other related contents were considered through a manual search on Google. Further searches were conducted through face-to-face visits to related organizations to collect inaccessible items on the Internet, including some documents and minutes.

key informant’s interviews

Participants were selected (Table 2) from among three groups of key informants (experts and relevant specialists, executives in organizations, and senior managers and policy makers) who had experience (rich knowledge and information) in relation to the phenomenon under study. We considered stakeholders in various areas of physical activity policy from the highest level of policy to the lowest level of implementation. Interviews were conducted from February to July 2021. Participants were selected using purposive sampling with maximum diversity, followed by snowball sampling.

Semi-structured interviews were conducted by an experienced male researcher who was a PhD student at the time of this study. All interviews were conducted face to face by prior appointment with the interviewees at their workplace. The interviews lasted between 45 and 60 minutes. At the beginning of each interview session, a brief explanation of the objectives was given. Then, the interviews were recorded with the informed consent of the participants and with an emphasis on the confidentiality of individual identities and their conversations. The data collection and analysis process were performed simultaneously until theoretical saturation. We used the interview guide, which was designed based on the conceptual framework of the research (MSF) to conduct the interviews. The interview guide was tested in three pre-interviews, and minor changes were made to the questions.

1) Problem stream: What are the unresolved problems in the field of PA in Iran?

2) Policy stream: What measures have been taken by the relevant organizations in Iran to solve the PA problems?

3) Political stream: What political factors affect PA policies in Iran? Is there political support at the highest level of government for policy-making PA in Iran?

Data Analyzes

The framework analysis approach was explicitly used in three stages of description, analysis, and interpretation (19). The description phase included conducting interviews and recalling important points during the interview, which were completed through footnotes during the interview. The interview was conducted right after the interview to have a high-performance reminder. By studying the implemented text several times and also the desired policy document, the researcher became familiar with the data. The analysis phase included classifying and identifying the main categories in the interview text and documents based on the components of the MSF (problem stream, solution stream, and policy stream). In the interpretation stage, the coding process was performed by two researchers (F-KH), and the codes with similar themes were placed in the same category. Differences in coding and classification were discussed by (F-KH). MAXQDA-10 software was used in this section to manage data analysis.

Trustworthiness

The criteria outlined by Lincoln and Guba18 were applied to ensure the rigor of the study. Member checking was carried out in meetings with the respondents to confirm the preliminary findings. The analytical process was reviewed by colleagues familiar with the qualitative approach. Moreover, the purposeful sampling with a maximum variation approach included participants from different levels of the policymaking hierarchy and enhanced the credibility of the data. Finally, re-checking the analytical codes with the experts in the field of PA strengthened the confirmability and credibility of the data.

In this study, as a result of reviewing 35 policy documents and 23 interviews with key informants, we categorized and described the results in the MSF, including problem stream, policy stream, and political stream.

Problem Stream

High Prevalence of Inadequate PA

According to studies, there is an uptrend in the prevalence of insufficient PA in Iran (reference), and society is not ready to change behavior. In a national study conducted in 2020 with the STEPS approach in people aged 18-64 in Iran, 34.5% of adults had low levels of PA (STEPS and Central Bank). Inadequate PA has always been a problem over the years. Stakeholders have tried to promote this behavior in society as one of the practical and effective solutions to reduce the burden of chronic non-communicable diseases by passing laws (legislation), policies, programs, and activities. However, according to the statistics provided, the policies and plans made in this regard in the country have not been successful and have not led to an increase in physical activity behavior.

Barriers to PA

There are several individual and contextual barriers that prevent citizens from engaging in PA from the interviewee's perspective. Depression and frustration, listlessness and lethargy, lack of mood and motivation, life worries (concerns of life), lack of life skills, and misconceptions about sports were among the most important things that key informants mentioned as individual barriers to not engaging in physical activities.

"…There is a hidden depression in our society: "Who is in the mood? I'm not! This is not laziness, this is not necessarily the same deep depression, but it is the depression and gloom that now exists in our society "(P5)

Perceived environmental factors

Urban and peripheral infrastructure is not based on the needs and expectations of people. Certain groups, such as the disabled, in the design of urban and residential complexes are not provided with suitable infrastructure for PA including cycling line, hiking, and other indoor sports activities. One of the senior managers of stakeholder organizations in this regard said:

“… Unfortunately, we have not done well in discussing the design of physical infrastructure so far. Our physical infrastructure is not proportional to the needs of the day and society's expectations of our sports structure. Residential complexes do not have adequate space for residents' sports and physical activity.” (P18)

Changes in people's lifestyles

The growth of urbanization, technological innovation, tendency towards sedentary jobs and leisure, and increasing use of private transportation vehicles in the current situation lead to changes in lifestyle patterns,reduced PA, and increased sedentary behavior, especially in the middle-aged people. This can be a serious threat to the health, economy, and labor of the society and can even have undesirable security consequences which requires the attention of the government.

"... The proportion of bicycle use for urbanized Iranians has decreased by 11 percent in the last 15 years, and the use of personal cars has increased by 30 percent, while in 2018, the use of the Internet by the people with a significant growth reached 64%, and 61.6% of households were members of social networks. (Central Bank Report, 2018)"

COVID-19 restrictions and international sanctions

The Covid-19 restrictions on jobs also in addition to sanctions have led to rampant inflation in society and, as a result, imposed heavy economic pressure on the people and government. It has affected all aspects of PA and sports from various stages of policy-making to public participation. One of the senior executives said:

"... The high cost of exercise is considered one of the components affecting people's preferences in physical activity. In recent years, the issue of rampant inflation caused by sanctions has also exacerbated this problem by multiplying sports equipment and services and club spending." (P13)

"… During the Covid-19 outbreak, sports venues and parks were forced to close, or their activities were restricted. In the current situation, this is not in the club owner's interest Neither the government can provide more support, nor the people are willing to attend or incur more costs." (P16)

Managerial-structural factors

There are several obstacles and challenges in the management of physical activities in related organizations, including manpower problems, technical problems, equipment and facilities, financial problems, planning, and implementation problems. Moreover, the existence of structural problems has led to the lack of a unified trusteeship and also the lack of a coherent inter-sectoral structure for the development and coordination of the implementation of physical activity policies.

"…The multiplicity of decision-making centers in the field of macro-sports policy in our country is really an annoying issue. This means that while there are several programs, we could not get a significant output from these programs, so all of these are due to the lack of a strong tutelage in the field of sports. (P18)

"... For example, in this non-communicable document, we have written the goals and strategies well, but we have problems in the main activities that should lead us to these goals. When writing activities, in documenting (compilation of documents), everything becomes a slogan-like activity, and, as a result, good executive operations are not performed to achieve these goals." (P3)

Policy Stream

Reviewing documents and analyzing key informant interviews shows that there are the following strategies to reduce sedentary lifestyle in the community:

Integration of PA services into primary health care

PA has been integrated into the primary health care delivery system as one of the basic interventions for non-communicable diseases (IraPEN), and it is offered in health centers and health houses through the national health information system (SIB: an abbreviation for the Persian equivalent of ‘integrated health system’) for people over 30 years old. The level of individuals’ PA was assessed by using a questionnaire designed in the SIB and, then, depending on the individual's condition, necessary care and advice, and training, follow-up is provided by health care providers and family physicians. However, the technical skills of service providers, high volume of job processes, technical problems of executive instructions, and incomplete service delivery cycles are among the challenges of providing this service in health centers.

One of the participants at the executive level in this regard said:

"... I do not think health care providers or even our doctors can teach clients the right exercises, because they do not have its knowledge. The existing instructions are not really enough and, on the other hand, there is not enough time. The number of clients is also high. Even some clients do not have time to sit. "(P7)

Holding national and global calendar campaigns and events

National and global calendar occasions provide an opportunity for public sports to be considered by officials and managers of institutions and organizations in the form of campaigns, festivals, and competitions.

Participants stated the lack of purpose, cross-sectioning, lack of public attractiveness, and low cost-effectiveness of these programs as campaign challenges and calendar events.

"…A while ago, Ministry of Education held collective and group programs for mountaineering. Now it is canceled." (P15)

Existence of a legal structure to promote PA in society

There are different legal structures in Iran in order to promote and develop public sports and PA in different strata, which are:

- Workers' Sports Federation and the corresponding workers' sports delegations in the provinces and cities

In order to encourage, persuade, and popularize sports among workers and various segments of the society, the Federation of Workers' Sports with the cooperation and interaction of the Ministry of Sports and Youth and also Ministry of Cooperation, Labor, and Social Welfare was approved in November 2012 and according to Article 22 of its constitution, Workers' sport was created.

Despite the high potential, these federations and sports delegations have not been able to lead different sections of society towards PA and sports. The focus of workers' sports federations, or in a way, the majority of federations in Iran, is on the championship sports of these groups, and has provided the ground for a serious deviation in the direction of the credits of these federations.One of the participants in this regard said:

"…With the creation of the federation, we distanced ourselves from workers' sports day by day. We created the workers' sports federation to gather two and more people and claim that our workers' sports have a place in the world, and our performance is good. The missing loop of workers' sports should be sought in the heart of factories and some workers' units for what was forgotten. How many workers exercise regularly? Is morning exercise held in factories? "(P19)

- Public Sports Federation and corresponding public sports delegations in provinces and cities

Public sports were established in 1983 in the country's sports organization and, in 1992, the public sports’ federation was established. Following that, between 1999 and 2003, sports delegations were formed in different provinces, whose most important task is the development and implementation of a public sports action plan in the country.

However, the superiority of the championship approach over the public is seen even in the goals and programs of this federation like other federations:

"Public sports in sports delegations have a professional and championship approach. The nature that the federations and the ministry ask us is professional sports. For us, the goal is to send our athletes to the Olympics and the national team." (P14)
Existence of defined sections responsible for the program in governmental and non-governmental organizations

These sections, which are mostly based on the regulations for the development and generalization of sports of government employees and also the executive regulations of Article 154 in government organizations and production and industrial units, are part of the units that are mostly marginal and their limited activities are also heroic.

the Supreme Council for Health and Food Security in the country

The Supreme Council for Health and Food Security was established in 2008 to expand coordination and inter-sectoral cooperation in order to maintain and promote community health and to adopt macro-policies and strategies in the field of public health. The council includes the president as chairman, the minister of health and medical education as secretary, and nine ministers and parliament speakers. This council is formed in the provinces under the name of Health and Food Safety Working Group of the province chaired by the Governor and with the participation of the heads of the province's stakeholders where the president of the University of Medical Sciences is the secretary of the council. The secretariat of the working group is also in the University of Medical Sciences.

Lack of active presence of managers in provincial council meetings and failure to fully implement the resolutions have always been matters of concern. On the other hand, the existence of some national plans, issues and emergencies of the health sector, and environmental health problems have always been a priority in PA, and it make these councils, despite their high potential, not to have a good support position in PA policy.

"...We have held every meeting for a non-communicable document in the governor, but no one has participated. Even the deputy did not attend; rather, they sent an expert who has no decision-making position. "(P3)

Political stream

This study, reviewed the political streams in PA after the Islamic Revolution of Iran (1978).

1. The Constitution of the Islamic Republic of Iran

The constitution is the highest legal document of a country and the official framework for drafting basic laws. Constitutions are at the top of the legal hierarchy. Given the importance of physical education, it is explicitly emphasized in the third paragraph of the third principle of Constitution:

The Government of the Islamic Republic of Iran is obliged to use all its means to achieve the goals mentioned in the second principle for the following matters:

Paragraph 3: Free education and physical training for all people at all levels as well as facilitation and generalization in higher education.

2. Support of the Supreme Leader

The promotion of PA in Iran is supported by the Supreme Leader, who is at the highest level of governance in Iran. He has given guidance for the promotion of PA and public sports in the form of general policies in various fields. (Table 1)

3. Support of the Parliament

In Iran, the parliament has the task of legislating and overseeing the implementation of laws., whose members have been elected by the people. Parliament has enacted the laws related to the implementation of general policies, as well as PA, and has notified the president for implementation.

4. Support of the President and the Cabinet

In Iran, the president is the second highest official after the Supreme Leader, who is primarily responsible for formulating government policies and programs as well as implementing them. In the field of PA, several by-laws and directives have been prepared, approved, and announced by the president and the cabinet. (Table 1).

5. Support of the Supreme Council of the Cultural Revolution

The Supreme Council of the Cultural Revolution is considered the supreme authority for policy-making, decision-making, coordination and directing cultural, educational, and research affairs within the framework of the general policies. In the field of PA, it has five independent resolutions for women's PA.

6. Support from various organizations and ministries

There are several internal documents, programs, and directives about promotion of PA in various institutions and organizations. On the other hand, we are faced with a number of documents, directives, and decision-making authorities for promoting PA.

7. Resolutions of the Islamic Council of the city

According to the constitution of Iran, these councils are policy-making authorities which can make decisions in the region under their protection in accordance with Islamic norms and laws. In the field of PA, in the five-year metropolitan development plans, there are approvals in promoting PA policies which are implemented by municipalities .

8. Impacts of International Organizations

In May 2004, the 57th World Health Assembly adopted Resolution No. WHA57.17 - the Global Strategy for Diet, Physical Activity, and Health. It was also recommended that member states develop national physical activity programs and policies to increase the level of physical activity in their population (20). In addition, in May 2008, the 61st World Health Assembly adopted Resolution No. WHA61.14 in the framework of the Action Plan for the Global Strategy for the Prevention and Control of Non-Communicable Diseases, which encouraged member states to implement national guidelines on PA for health (20).

The Moscow Declaration on Non-Communicable Diseases was signed by the Ministers of Health in May 2011. In addition, The UN Political Statement on Non-Communicable Diseases was approved by the Heads of State in September 2011, and the State pledged to formulate or strengthen multi-sectoral national policies and programs to prevent and control non-communicable diseases based on national indicators and conditions by 2013(7) .

In May 2013, the World Health Assembly adopted the WHO Global Action Plan for the Prevention and Control of Non-Communicable Diseases (2013-2020) to fulfill these commitments. According this plan, countries pledged to control and evaluate non-communicable diseases by targeting four key risk factors, including a 10 percent reduction in the prevalence of inadequate PA. Establishing a surveillance system for risk factors of non-communicable diseases since 2004, compiling the National Document for Non-Communicable Diseases in 2015, and keeping the National PA Plan in 2016 were taken by the Iranian health system following these commitments.

Policy windows

Attention to the issue of PA in Iran has two sources, the first of which originates from the principles of the constitution and the general policies of government, and the second is the impact of international events and Iran's commitments to international organizations, especially the WHO.

General health policies announced by the Supreme Leader and Iran's participation in the international forums and countries' commitments to adopt policies for promoting PA in society as a strategy to combat the burden of non-communicable diseases and attract the attention of policymakers has created policy windows to reconsider PA in Iran, which led to the development of a national document on non-communicable diseases and the subsequent national program of PA in Iran. Despite the fact that all three streams are coming together, and the policy windows is open, perceived subjective barriers and various underlying factors that were mentioned in the previous section, hinder the usage of the current policy windows. On the other hand, the developed policies do not have the necessary efficiency and effectiveness. It seems that the main problems in cross-sectoral cooperation for the implementation of health policies can be not only due to the weak support of the Ministry of Sports and other ministries in the field of policy, but also due to the political structure and administrative bureaucracy of the country. It has hindered the facilitation of inter-sectoral cooperation among organizations and ministries. On the other hand, differences in missions, and goals of executive organizations have led to different approaches and sometimes conflicts of interest.

This study was conducted by using the MSF to analyze the process of change in the policy making of PA in the Iranian political agenda. The results of this study showed that the most important perceived subjective barriers and contextual factors related to PA were listless and lethargy, the lack of interaction and cooperation between the stakeholders, the lack of priority for PA for the stakeholders, and the lack of financial, human, and equipment resources. These factors are multidimensional in nature and prevent the problem of PA from being placed on the agenda or the implementation of policies that have been approved after the agenda-setting.

Policies and laws passed in recent years in Iran show that PA policies are on the agenda. However, this study identified a set of multidimensional problems related to PA policies. The most important of these problems are championship and professional approach in the Ministry of Sports, restrictions on international sanctions and the COVID-19 pandemic, and managerial-structural problems and individual obstacles, including listless and lethargy, which have hindered the successful implementation of these policies. Therefore, the focus of political actors should be on adopting alternative policies and effective use of available resources to have better policy implementation. Policymakers need to know that strengthening cross-sectoral cooperation and stakeholder engagement is essential to implementing such policies through health and food safety council as well as sports and physical education council, which have the power to coordinate, monitor, and demand approved policies. Health indicators and the active role of political actors and the media in this period can push for policy change. However, this study can be used by decision makers and policy makers in the policy-making process by identifying facilitators of policy window and factors that obstacle better use of this opportunity to affect the actors who play a vital role in the implementation phase. This study, through using the MSF, aimed to analyze the process of change in policies of PA in the political agenda. The results of study revealed the most important individual barriers and underlying factors related to physical activity, listless and lethargy in people, lack of interaction and cooperation between stakeholders, lack of priority of PA for the stakeholders, and lack of financial, human, and equipment resources. These multidimensional factors prevent the problem of PA in the agenda setting or implementation of policies that have been approved.

The high prevalence of a risk factor or disease in society is one of the influential factors in attracting policy maker’s attention to put it on the policy agenda (21). The main concern in the PA is that despite the structures, programs, and measures taken in Iran by various stakeholders over the past years, including the National PA Program of the Ministry of Health, physical inactivity is still one of the important risk factors for non-communicable diseases. 15). Studies in other countries also show that despite the adoption of various policies, sedentary lifestyle, especially in the age group of 30–59 years old, is quite prevalent (22, 23). Increasing urbanization, technology, inclination to occupations, and sedentary leisure has changed the traditional active lifestyle and led to an increase in sedentary behaviors in society, which can highlight the problem of physical activity policies for policymakers (24) and draw their attention to remove barriers of physical activity behavior and adopt appropriate policies to current structures. Various interventions and solutions have been implemented to promote PA by various stakeholders in Iran. For example, after the integration of PA assessment in the primary health care system, a turning point occurred in the assessment of PA status in Iran, which is done through national health information system (SIB) (25). However, the lack of sufficient skills of service providers to the training of physical activity, high volume of job processes and technical problems of executive instructions have hindered the effectiveness of measures taken to improve physical activity behavior in target groups. The results of study by Wattanapisit et al., Reviewing PA counseling in primary health care conducted in 2020, showed that lack of knowledge or training of health care providers can be one of the main barriers to providing PA counseling (26). In the United Kingdom, the National Institutes of Health and Care (NICE) recommends that all patients receiving primary care be evaluated for PA to identify those who do not have the recommended level of physical activity but can benefit from it. Other interventions in Iran include the adoption of relevant laws in parliament, the development and communication of executive regulations for the development and generalization of sports in government employees, and the executive regulations of Article 154 of the Labor Law to promote the physical activity of employees and workers in governmental organizations and industrial units.

However, the implementation of these strategies has been accompanied by challenges over time and has been affected by various conditions, especially economic conditions. The most important of them are financial problems, lack of hardware equipment in these units, and non-compliance with the law under excuses. At the same time, the pressure of economic sanctions, as well as the problems caused by the Covid-19 pandemic, has added to these problems. Kabiri et al. confirmed the impact of sanctions on the non-implementation of cancer prevention policies in Iran. Kabiri and Taghizadeh et al. also confirmed the impact of sanctions on childhood obesity prevention policies in Iran (27).

Marian et al. in Maryland reported that lack of support from business leaders, limited resources, especially in small units, limited physical space and equipment in work units, and lack of incentives provided by the government were barriers to the implementation of PA policies (28). Cruiser et al. in their study, paid attention to equipment and facilities for providing optimal intervention as challenges in PA interventions in adults (29). Heinrich et al. believed that funding is critical to the success of any intervention (30). Vancampfort et al. also considered the provision of the necessary financial resources as one of the necessities of these policies by conducting a systematic review of PA policy interventions in sub-Saharan Africa (31). Holding national and global calendar campaigns and events is an objective manifestation of the participation and cooperation of various social, cultural, and economic strata in public events. In addition to promoting the slogan of the occasion, these campaigns also focus on sensitizing the people and promoting the culture of public sports in the community. These potentials have been confirmed in other studies (32–34). However, the success rate of these campaigns in achieving the goals requires high political support, high commitment of members and acting leaders in achieving the goals, providing financial resources, and having experienced employers and organizing members (10).

Although various stakeholders in Iran have adopted different strategies, these strategies are affected by obstacles and challenges over the years of implementation that have led to their improper implementation, not achieving the necessary effectiveness and efficiency. Therefore, it seems necessary for policymakers to focus on removing obstacles and challenges and reform or adopt policies which are appropriate to the current situation.

The findings of this study showed that there is a strong national and international political support for the development of public PA in Iran. The first source of support is the constitution. The constitution is the highest legal document of the country and the official framework for drafting basic laws. In Iran, the third principle of constitution explicitly emphasizes PA. The second source of political support is the Supreme Leader, who is the highest authority for the approval and acceptance of policies in Iran (21) and, according to Article 110 of the Constitution, has the task of determining the general policies of the government. The Supreme Leader has emphasized the physical activity in general policies. Moreover, through his influence and power, he can use and demand resources and forces in coordination to achieve the goals of the physical activity development (10). The third supportive authority is the parliament; in addition to its duty to legislate and determine the laws of the country, it can influence the implementation of policies through monitoring the proper implementation of laws (35). The fourth source of the support is the President and its Cabinet, who can play a supportive role through the approvals of the Cabinet as well as the High Council for Health and Food Security, and the High Council for Sports and Physical Education (21). These councils have been formed to promote cross-sectoral coordination and cooperation and adopt macro-policies and strategies in the field of health and physical education. Through these councils, the president can manage and demand the cooperation and participation of all ministries in health and physical education activities. The work related to these councils in the province is formed with the same goals, job descriptions, and corresponding members. (36). The fifth source of support is the Supreme Council of the Cultural Revolution. This council is considered the supreme authority for policy-making and directing the cultural, educational, and research affairs of the country within the framework of the general policies of the country. Also, its decisions and approvals are as binding as the law (37). The sixth sources of support are the Ministries of Health and Medical Education, the Ministry of Sports and Youth, the Ministry of Cooperatives, Labor, and Social Welfare, and also the Ministry of Education, which play their supportive role by developing documents and programs at the ministry level within the framework of laws and national documents. The seventh sources of support include the World Health Organization and the International Federation of Public Sports and Workers' Sports, which provide guidelines and action plans as well as oblige countries to develop a national action plan to implement for recommendations. (38, 39).

The findings of this study indicate that despite strong political support and legal structures to promote physical activity in Iran, it seems that public PA is still neglected by officials, especially sports officials, and its role, importance, and position are not properly considered. The findings of this study indicate that despite strong political support and legal structures to promote PA in Iran, it seems that public PA is still neglected by officials, especially sports officials, and its role, importance, and position are not properly considered. Findings of other studies in Iran also confirm this (40, 41).

Evidence show that there is a significant gap between policies formulated and what is happening in practice and, therefore, most public policies do not work as well as expected. The findings of this study indicate the lack of interaction and cooperation between stakeholders, lack of priority for PA for stakeholders, and lack of financial, human, and equipment resources. Adikari et al. reported that coordination problems between stakeholders pose many challenges in implementing health system policies (42). Casey et al. reported that the lack of participation of key stakeholders in a community PA program would lead to the instability of these programs. (43). This challenge has been reported in other policy analysis studies in Iran. Kabiri et al. reported that there is no favorable cross-sectoral cooperation between the Ministry of Health and other stakeholders in gastrointestinal cancer prevention policy (21). Khodayari et al. also reported this problem in the study of AIDS policies in Iran (15). The results of the study by Taghizadeh et al. showed that poor coordination between stakeholders is one of the challenges of nutrition policies that leads to fundamental problems in policy-making and implementation (27).

The findings of this study showed that due to the multi-sectoral nature of PA, various ministries and organizations play a role in this field, and we are faced with multiplicity in decision-making, so the lack of a strong single reference in this area is evident. This has led to parallel work, waste of resources, multiplicity of goals and approaches, and confusion in the field of health-oriented PA policy. However, the legislature has designated the Ministry of Sports and Youth as the main custodian of sports in the country, but the first priority of this ministry is championship and professional approach. On the other hand, due to the political structure of the country, it has a low level of influence and power compared to other equal institutions and has not been able to appear as a powerful authority. The next point is that due to the nature of public PA and the breadth of needs and requirements in this area, the Ministry of Sports and Youth alone is not able to implement policies and meet all the needs of the society. Policies and laws passed in recent years in Iran show that PA policies are on the agenda. However, this study identified a number of multifaceted problems with PA policies. The focus on the championship and professional approach in the Ministry of Sports, the limitations of international sanctions and the Covid-19 pandemic, managerial-structural problems and personal obstacles such as listless and lethargy have hindered the successful implementation of these policies, but the good window policy has not been used. Therefore, the focus of political actors should be on adopting alternative policies and more effective use of available resources to better implement the policies. Policymakers need to be aware that strengthening cross-sectoral cooperation and stakeholder engagement is essential to implementing such policies through health and food safety councils as well as sports and physical education, which have the power to coordinate, monitor, and demand approved policies. Highlighting health indicators and the active role of political actors and the media in this period can push for policy change. This study explained the facilitators of policy windows and factors that hindered better use of this opportunity. Therefore, policy makers can use the results to influence the actors who play a vital role in the implementation phase.

physical activity	PA
multiple streams Framework	MSF
Scientific Information Database	SID

Ethics approval and consent to participate: This study was approved by the regional ethics committee of Tabriz University of Medical Science under the following Approval ID: IR. TBZMED. REC.1398.569. We obtained informed consent at the beginning of the interviews by stating the objectives of the study, explaining how participants participated and how the data were collected and recorded. Moreover, privacy and confidentiality of all information, including participants' names, interview files, and writings, were observed, and participants' right to withdraw was reserved at any stage of the research for any reason.

Consent for publication: Not applicable

Availability of data and materials: The datasets used and / or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: The Authors did not receive any specific funding for this work

Authors' contributions: Study design: HN, BF, RK and SP. Study conduct: HN, BF, and AK. Data collection: BF, AK and HN. Data analysis: HN, RK, and SP. Data interpretation: HN, BF and AK. Drafting manuscript: HN, BF and RK. Revising manuscript and content: HN, SP, and AK. Approving final version of manuscript: All authors. HN takes responsibility for the integrity of the data analysis.

Acknowledgements: We thank all those who supported us to complete the study.

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Table 1- Policy Documents Checked in the Field of Physical Activity in Iran

Source of Support

Policy document

Constitution of the Islamic Republic of Iran

The third principle of the constitution

Supports of Supreme Leader

Eighty general policies of the Sixth Development Plan of the country Issued by Supreme Leader

General health policies announced (issued) by the Supreme Leader in 2014

General anti-narcotics policies announced by the Supreme Leader in 2006

General Policies of Resistance Economy announced by the Supreme Leader in 2012

Vision Document of the Islamic Republic of Iran on the horizon of 1404 AH

Support of the Parliament

Law on Economic, Social and Cultural Development Programs of the country (first to sixth)

Article 154 of the Labor Law of the Islamic Republic of Iran

Law on Direct Taxes (Tax Exemption for Sports)

Support of the President and the Cabinet

regulations for the development and generalization of sports of government employees

The National Program for Promoting the Health and Vitality of Women and Girls through Sports issued by the 2017 Council of Ministers

Executive regulations subject to the note of Article (154) of the Labor Law issued by the Cabinet

Strategic document of the comprehensive system of development of physical education and sports of the country

National Document for the Prevention and Control of Non-Communicable Diseases in the period of 2014 to 2025

Approval of the formation of the Supreme Council of Sports and Physical Education

Resolutions of the Supreme Council of the Cultural Revolution

Socio-cultural policies of women's sports in the country, approved by the 407th session on 7/22/76

Amendment and completion of paragraphs 1 and 4 of the socio-cultural policies of women's sports in the country, approved by the 410th session dated 4/9/76

Policies to improve the leisure situation of women and girls, approved in the 513th session of 12/20/81

Policies and strategies for promoting women's health, approved in 613 sessions dated 8/8/86

Policies and cultural priorities of the Physical Education Organization, approved in the 565th session, 4/21/84

Table 1- Policy Documents Checked in the Field of Physical Activity in Iran(continued)

Source of Support

Policy document

Support from various organizations and ministries

National Physical Activity Program to Promote Health in the Islamic Republic of Iran (Ministry of Health)

Transformation, Excellence and Foresight Document of the Federation of Public Sports (Office of Public Sports Development of the Ministry of Sports and Youth)

Sports Strategy Document of Ministry of Cooperatives Labour and Social Welfare (Compiled by the Strategic Sports Council of the Ministry in 1995)

Physical Education Program with Family (Ministry of Education)

Teachers Sports Development Plan with Priority for Women (Ministry of Education)

Resolutions of the Supreme Council of Health and Food Security and the Working Group on Health and Food Security of Province (16. Resolutions)

Operational plan and provincial document for prevention and control of non-communicable diseases and related risk factors in the period 1397 to 1404

National Building Regulations (Ministry of Roads and Urban Development)

Support of the Islamic Council of Metropolises

Five-year cultural and social development plan of metropolitan municipalities

Support from international organizations

Commitment of countries to implement the provisions of various resolutions and guidelines of global health: 2004-2010-2018 to 2030 and 2020 and the United Nations and the Cabinet of Ministers

Support of the World Federation of Public Sports

Support from International Sports of Workers and Amateurs Confederation

Table 2-Profiles of key informants of policy analysis interviews

service history	Position	Gender	Organization	No
8	Vice Chancellor	Female	Department of Sports and Youth Affairs	1
16	Head of the Dean of Center	Male	Vice-Chancellor of Health Affairs	2
20	Dean of Department	Male	Vice-Chancellor of Health Affairs	3
8	faculty member	Female	School of Health	4
30	Dean of Department	Male	Ministry of Health	5
25	Psychiatrist	Male	Research Center of Behavioral Sciences	6
7	Physician	Female	Urban Health Center	7
23	Vice Chancellor	Female	General Administration of Education	8
30	Office boss	Male	General Administration of Education	9
12	chif expert	Male	Administration of Education	10
10	Team leader	Female	Administration of Education	11
25	Vice Chancellor	Male	Department of Sports and Youth Affairs	12
18	chif expert	Male	Department of Sports and Youth Affairs	13
27	Chif expert	Female	Department of Sports and Youth Affairs	14
18	Vice Chancellor	Male	Tabriz university (Faculty of Physical Education)	15
20	Managing Director	Male	Cultural and sports club	16
30	chair of the board	Male	Public Sports Federation	17
3	chair of the board	Male	Workers' Sports Federation	18
20	Dean of Department	Male	Department of Cooperative, Labour and Social Welfare	19
20	Vice Chancellor	Male	Tabriz Municipality	20
27	faculty member	Male	The Research Center for Social Determinants of Health	21
20	Former boss	Male	Construction Engineering Organization	22
18	section manager	Male	National Tax Administration	23

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Agenda-setting policy analysis on Iranian physical activity promotion policies: An application of Kingdon’s Multiple Streams Framework

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