This study is the first to assess the extent the implementation of government policy actions to improve the PA environment. The process of assessing government actions generated an evidence document providing an overview of the government actions in place which support PA, revealed areas of relative strength as well as gaps in implementation, and provided priority recommendations for strengthening PA policy implementation in the future. The evidence document was praised by stakeholders who participated in the study for providing them with an overview of the available policy documents in Ireland.
Complementarity of the PA-EPI with other Policy Research Resources
The process of generating the evidence document was supported by previous work using the HEPA PAT and informed by some of the policy information collected by the MOVING database. The HEPA PAT has been recommended as a comprehensive tool for performing PA policy analysis (Klepac Pogrmilovic et al., 2019a) and it has been utilised in other European countries to conduct analyses of PA policy in numerous European countries. However, reviewers of extant PA policy tools have noted that the PAT is “more suitable for an audit than an assessment” (Klepac Pogrmilovic et al., 2019a p9), and further, that researchers should look into the possibility of complementary tools. This study highlights the complementary of the PA-EPI tool with other instruments available to PA policy researchers like the HEPA PAT.
Implementation strengths and gaps
The results of this study reveal that the infrastructure support domains were judged to be better implemented than the policy domains. This is a nearly universal pattern for studies utilising the Food EPI (Vandevijvere et al., 2019; Djojosoeparto et al., 2022). Further studies will reveal whether a similar pattern emerges for the PA-EPI as well and hopefully provide insight into the dynamics underlying these patterns. The implementation status of the indicators suggest that Ireland can build on its relative strengths in the Mass Media and Monitoring and Intelligence domains. However, they also suggest that there are implementation gaps regarding transport, urban design, healthcare and health in all policies.
The low implementation ratings in the healthcare domain appears to corroborate previous research into PA promotion by healthcare professionals in Ireland. Cantwell and colleagues (2018) reported that a majority of healthcare professionals, in Ireland, did not provide cancer patients with PA advice that aligned with guidelines, while Cunningham and O’Sullivan (2021) report that only 30% of healthcare professionals, Northern Ireland and the Republic, report receiving adequate training for prescribing PA to older adults. The Republic of Ireland has a policy for promoting PA, among other lifestyle risk factors in healthcare settings, Making Every Contact Count (MECC). The findings of this study, and others which we have cited above, suggest that the implementation of MECC has not been a success. This may be explained at least in part, by the fact that an internal report commissioned by the HSE found that the health service lacked organisational readiness for this intervention prior to its enactment, It is perhaps unsurprising, therefore, that the expert panel recommended that increasing the capacity of staff across health and social care setting to promote awareness of physical activity and better connecting community PA programmes and healthcare be implemented as a priority.
Prioritisation
The panel of independent experts prioritised actions in the policy and infrastructure support components of the PA-EPI. In the policy domains the panel recommended implementation actions in the Education, Healthcare, Mass Media, Community and Sport domains. A difference between the PA-EPI and the Food EPI is that policy domains of the PA-EPI arguably represent a greater number of independent health promoting settings than the Food EPI. There is a potential equity concern as targeting different settings may have disproportionate benefits for different demographics. Potential methods for reconciling differences of opinion is to ensure that a certain number of actions are prioritised per domain or based on a lifecourse perspective
A point of discussion is that some of the highest prioritised actions corresponded to indicators that had a relatively strong implementation rating. An implementation recommendation that received a high prioritisation rating was the proposal to establish a long term coordinated effort to promote PA opportunities in the media. It is also noteworthy that stakeholders did not prioritise implementation recommendations in the urban design or transport domains in spite of the identified implementation gaps in these domains. Future reasons may explore reasons apparent discrepancies between identified gaps and prioritised implementation recommendations.
Strengths and limitations
This study has important strengths. It is the first to utilise the PA-EPI tool to generate insight into PA policy and hence addresses a knowledge gap regarding the assessment of government action on the issue of PA. Though the PA-EPI is a pioneering approach in the domain of PA policy, it is based on internationally developed and validated methods used in the domain of food policy.
A second strength of the study is the independence of the stakeholders involved in rating and prioritisation. Though the research process engaged public officials to ensure that the evidence document is comprehensive, the rating of implementation was conducted by people who were not incentivised to provide positive findings as public officials tasked with performing a self-assessment.
This study has some limitations that should be acknowledged. The workshop component was attended by a small sample of stakeholders (n = 7 stakeholders, representing the Education, Sport, Community and Health sectors). Attendance at the workshop may have been affected by scheduling conflicts and the legacy of the COVID-19 pandemic or rates at that time may have affected the willingness of stakeholders to participate in an in-person workshop. The small sample and the spread creates the possibility that a particular viewpoint is overrepresented in the output of this exercise. The challenge of potential selection bias has been previously reported by Yamaguchi and colleagues (2022) who performed an assessment using the Food EPI in Japan. Researchers need to consider in early stages of the process how to ensure that the stakeholders involved in the later stages represent a variety of perspectives with differing domains of expertise.
A second limitation is that the independent panel (n = 13) may have been presented with too many options as part of the prioritisation exercise. Further, the implementation recommendations were not evenly distributed across the domains with a large number of recommendations pertaining to the education domain which in turn led to focus on one part of the life course. A concern was raised that that the number of recommendations presented biased the results of the prioritisation exercise to the advantage of younger demographics. While the number of recommendations provided to the panel for prioritisation was reduced at the workshop, this process should be made highly rigorous to avoid any concerns. Researchers should consider methods for limiting the number of recommendations presented for prioritisation both in total and per domain.
A final limitation is the availability of information on best practice exemplars used for comparison in the evidence document. Early studies utilising the Food EPI tool noted that policies put forward as BPEs were often not evaluated for real world impact and hence not ideal ‘gold standards’ (Vanderlee et al., 2019). A benefit of conducting further assessments utilising the PA-EPI is that it will provide examples of good practice which can be replicated to address implementation gaps.
Recommendations for future studies
A study of the relative contributions of the GPSs and policy subdomains is needed to develop weightings system for the PA-EPI. The weighting system would assign a relative importance for each of the GPIs for creating healthy PA environments and allow the calculation of a single PA-EPI score for implementation at step six of the progress. This score facilitates cross comparison of national PA EPI implementation ratings and advance the use of the PA-EPI as a PA policy benchmarking tool. Though the ratings provided by the expert panel in this study suggest that there is substantial scope to improve implementation status of PA policy in Ireland, future studies can confirm whether the Republic of Ireland is a laggard or a pioneer on this issue. The benchmarking feature of the PA-EPI tool addresses a noted gap in the PA policy research literature (Gelius et al., 2020)
Further studies utilising the PA-EPI are needed, in particular in low and middle income countries. Scoping reviews have demonstrated that PA policy research is overwhelming conducted in a few high income countries (Rütten et al., 2016; Klepac Pogrmilovic et al., 2018), indicating that the field of PA policy research needs to diversify. Further, inactivity is increasing in developing countries as the dynamics that drive inactivity in developed countries emerge or are adopted (Rütten et al., 2013).