Development of the health promoting sports club—national audit tool

Abstract Background Sports clubs have requested support from national governing authorities to invest in health promotion (HP), by developing policies, guidelines and dedicated funding. This article outlines the development of a national audit tool to review policies development and implementation to support HP in sports clubs. Methods A five-step process was undertaken by an international project team: (i) a rapid literature review to identify items assessing policies in physical activity, HP and sports, (ii) a thematic analysis to categorize items, (iii) a Delphi method to analyze item relevance, country specificity, reformulation, validation and organization, (iv) face validity through an online survey and in-depth interviews with expert representatives on physical activity and sports and (v) audit tool finalization though project team consensus. Results Eight sources were reviewed with 269 items identified. Items were coded into 25 categories with 3 broad themes: policies, actors and settings-based approach. The Delphi study extracted and refined 50 items and categorized them into 10 sections. After revisions from 22 surveys and 8 interviews, consensus was reached by the international project team on 41 items categorized into 11 sections: Role of ministry or department; Policies; Communication; Implementation and Dissemination; Evaluation and Measurement methods; Sub-national-level policies; Funding and Coordination; Participative approach; Actors and Stakeholders; National sporting events; Case studies and Implicated stakeholders. Conclusion To progress HP in the sports club context it is necessary to understand existing national-level policies. This national audit tool will aid in monitoring and assessing national policies for health promoting sports clubs.


N
ational health policies are strong indicators of a country's support mechanisms for creating a healthier society. 1 Health policies can be either formal or informal that 'define priorities and action parameters to respond to health needs, available resources and political pressures'. 2 Current policies rarely take into account the broader potential of settings-based health promotion (HP), where settings are considered as 'places or social contexts where people engage in daily activities in which environmental, organizational and personal factors interact to affect health and well-being'. 2For example, several national policies exist to promote physical activity at the individual level through sport provision 3,4 without considering the broader HP potential of sports clubs as a setting.Previous research highlights that one in five European countries had government-supported 'Sport for Health' programmes in place, while 1 in 3 had similar programs in place to promote physical activity. 5dditionally, the 2008 European Union (EU) Physical Activity Guidelines highlight the importance of sports clubs offering physical activity opportunities for the entire population, providing sports infrastructures within an acceptable distance (20 min by car or foot), and state the important role clubs can play in gender equality, social values and cultural development. 6Before this, HP through sport was mentioned in the EU White Paper on Sport 7 and more recently, physical activity promotion specifically through sport is incorporated in the Global Action Plan on Physical Activity 2018-30. 3rganized sports clubs are 'private, non-profit organizations formally independent of the public sector, including volunteer members and a democratic structure, having sports provisions as their main aim'. 8In Europe, sports clubs reach a wide audience with over 33% of the population participating in an organized sports club. 9Thus, sports clubs are active agents embedded in their society to promote citizenship, employment and inclusion. 10Sports clubs are unique settings because they can naturally promote the physical activity component of health, 11 but they can also be informal venues to promote mental, social and well-being health outcomes. 12Since the early 2000s, researchers have explored the concept of HP in the sports club setting 13,14 and in the process, developed a model and framework to guide the design, planning and implementation of HP interventions. 15The resulting health promoting sports club (HPSC) model and framework are based on a whole-system HPSC approach 16 where HP is incorporated into daily sports club practices as well as all formal and informal policies. 17Recent research was undertaken to develop a settings-based model of the HPSC that includes both internal (participants, coaches, managers and the sports club as an organization) and external stakeholders (sports federations, public health agencies and government authorities) that influence a sports club's ability to promote health. 15By incorporating multiple levels in the model, stakeholder roles for promoting health are clearly defined through four health determinants (economic, environmental, organizational and social) at each level.The HPSC model highlights the importance of government support, policies, education and financing, which are all essential elements of the HPSC approach.Previous research combined six case studies from five countries to establish the current state of HPSCs. 18Two major 'themes' emerged: (i) the investment in HP policies and practice by national sports organizations and sports clubs; and (ii), the inclusion of a wide range of stakeholders such as the community and parents of sports participants.Nevertheless, research to determine the extent of support provided to sports clubs to undertake HP, either directly through national levels or through affiliated sports federations, has been minimal.Although sports clubs can increase HP actions internally, top-down support is essential to provide guidance, policies, strategies and resources. 13,19A recent editorial described four types of HP in this setting: (i) as an outcome of the provided sport, (ii) sport used as a tool to create positive changes in a specific health determinant, (iii) HP in sport targeting a specific population or behaviour and (iv) the whole-system of sports incorporating all stakeholders and health determinants. 17Currently, little research has been conducted specifically on HP policies generated at the national level to support sports clubs to go beyond providing opportunities to participate in sport and physical activity, but to also promote health in a broader sense (physical, mental and social) and position themselves within the community to become agents of change.
In recent years, a number of frameworks and tools to monitor PA promotion at national levels, including the Health-Enhancing Physical Activity Policy Audit Tool (HEPA-PAT), 20 the Comprehensive Analysis of Policy on Physical Activity framework 21 and the Monitoring Framework for the EU Council Recommendation on HEPA Across Sectors 22 have been established.Although useful, these tools are limited to PA promotion without considering the broader HP capacity of sports clubs.
This study describes the development of a national audit tool (NAT) that can be used to assess whether existing national policy frameworks support the implementation of the HPSC approach.The guiding question was: 'How is HP in sports clubs supported through national-level policies and action plans?' with several secondary questions including: (i) 'what policies and support exist?'; (ii) 'how are the policies implemented and disseminated?';and (iii) 'how are the policy results evaluated?'.

Methods
A mixed-method, iterative study design 23 was used to develop the HPSC-NAT.The project consisted of five primary steps: (i) a rapid literature review; (ii) indicator formulation and selection; (iii) online surveys; (iv) in-depth interviews; and (v) finalization of the HPSC-NAT.An international project team including nine researchers in sport, HP and public health from France, Ireland, Sweden, Finland, Belgium and Australia and one expert from the WHO Regional Office for Europe (WHO/Europe) was established.The project advanced over nine meetings from December 2020 through September 2021.The first meeting oriented the international project team towards the objective of creating the HPSC-NAT, the following four formulated sections and items of the HPSC-NAT for presentation to members of the EU HEPA focal points network, 5 two follow-up meetings validated reformulations from online surveys and in-depth interviews, one meeting was conducted with the national EU HEPA focal points (national representatives appointed by EU Member States) 22 to explain the audit tool and invite interested parties to take part in the online survey or interviews and a final meeting was held with a WHO/Europe representative to finalize the tool.
Step 1: rapid literature review To develop a preliminary list of items, a rapid literature review was conducted by two project team members.Rapid literature reviews allow for a targeted search based on researcher's knowledge subject in literature and previously used data. 24The rapid literature review protocol included establishing criteria to search for primary data sources focussing on HP and/or physical activity policies, guidelines and analysis tools published or translated into English.The following eight sources were identified and reviewed for indicators: the English version of the CAPLA-Sante ´,25 three versions of the HEPA-PAT (English, Japanese and French), 20 the HPSC strategies and indicator list, 15 the e-PROSCeSS macro-level questionnaire, 26 Sports Club for Health (SCforH) indicators and guidelines 27 and the policy status review of HPSCs. 18ep 2: indicator formulation and selection Indicators identified during Step 1 were coded into categories in an excel spreadsheet and qualitative content analysis techniques were used to extract and interpret data.28 Indicators were analyzed to ensure relevance with the HPSC approach, remove country-specific indicators, identify and condense similar indicators and remove duplicates.Once indicators were cleaned within their respective categories, an initial rewording was made by two researchers (S.J. and A.V.H.).The wording of items was adjusted to reflect the HPSC approach rather than a single health behaviour.For example, the phrase 'beyond sport participation' was added to most items to emphasize that the HPSC approach has a vision to promote mental and social health rather than just focussing on physical health benefits of practicing sports.They were then presented to the project team as thematically categorized items and a modified Delphi method 29 was used to select, discuss and refine the items during four iterative meetings.After each meeting, new versions were sent to project team members for additional comments and refinement.Categorized items and sections were refined until the team reached consensus on included sections, items and wording. Inaddition to the preselected items, team members could propose other relevant items to include in the audit tool and suggest the best section for inclusion.For example, adding items regarding implicated stakeholders who helped to complete the audit tool.The audit tool sections include all agreed upon items.
Step 3: online surveys Thirty physical activity experts, researchers and policy makers from the HEPA Europe Network, the SCforH network and the national EU HEPA focal points, from 30 countries were invited to respond to an online survey via LimeSurvey from April to May 2021 for face validity of the audit tool.Potential respondents were emailed an invitation and a detailed description of the project along with the participation link.Reminder emails were sent after 2 weeks.Surveys were anonymous and respondents could opt out at any time.Upon clicking the link, respondents answered demographic questions (gender, current work position, country and knowledge of the SCforH network or the HEPA Europe network).Each item from the audit tool was presented in its respective section.Participants were asked to respond using a 4-point Likert scale (totally agree, agree, disagree and totally disagree) to the following section questions: 'You have understood the section', 'You think the section is clearly formulated', 'You know how to respond to the section', 'You think the section can be completed for your country', 'You can find the necessary information to this section for your country', 'You think the section is relevant to review policies supporting HP in sports clubs'.At the end of each section, participants were given the opportunity to include additional comments: 'Do you have any reformulation suggestions or remarks for a specific question in this section or for the whole section in general'.They were not asked to complete the audit tool.Respondents were then asked to rank each section in order of Development of the HPSC-NAT i29 importance to evaluate HPSC policies.Quantitative data were analyzed with descriptive statistics through Excel Quick statistics and qualitative data were analyzed by two researchers (A.V.H. and S.J.) through qualitative data coding methods. 30Section ranking was analyzed by a weighted scoring method whereby each time a section was ranked as first (most important) it was assigned 10 points, 2nd rankings received 9 points, 3rd received 8 points etc., until finally, 10th place received 1 point.The mean scores were used as placement for rankings (highest mean in first place). 12,31If sections had the same mean score, minimum and maximum scores were compared with choose the appropriate placement.
Step 4: in-depth interviews Twenty-eight national EU HEPA focal points were briefed on the HPSC approach and audit tool during a dedicated meeting before being invited to participate in an in-depth interview.Invitation emails were then sent out to the focal points in early May 2021.Individual interviews were conducted from late May through early September 2021 and lasted 1.5 h each.A working copy of the HPSC-NAT was sent 1 week in advance of each interview so participants could review the content.During the interview, participants were asked the same demographic questions as in Step 3.Then, the interviewer (S.J.) went through each section and asked if each item was easily understood, any suggested changes and comments.Notes from each interview were detailed and coded in an excel spreadsheet.Once all interviews were completed, qualitative data analysis was conducted by two researchers (S.J. and A.V.H.). 28Suggested changes were considered by the international project team if at least two participants made the same or similar comment as noted in the coding process.

Step 5: HPSC-NAT finalization
The project team met for two finalization meetings where suggestions from the survey and in-depth interviews were discussed and adjustments to sections or items were made with majority consensus.

Results
Step 1: rapid literature review From the 8 primary sources examined, 269 total items were identified: 17 in the CAPLA-Sante ´,25 76 from the three HEPA-PAT versions, 20 18 from HPSC strategies, 15 26 from the e-PROSCeSS questionnaire, 26 45 from the SCforH guidelines 27 and 84 from the policy status review of HPSCs. 18Three extra items were added by the project team to gauge a country's knowledge on HP; e.g.: 'Is HP a well-known or well-understood concept at the national or local level?' and 'Is settings-based HP used when planning and developing policies?'.

Step 2: indicator formulation and selection
Once the 269 items from Step 1 were analyzed, 68 items remained (see figure 1) and were coded into 25 categories (i.e.policy, funding, support, network, orientation, partners etc.) with three broad themes emerging: policy, actors and settings-based approach.Categories and items were reviewed for relevance to the HPSC approach with 50 items being retained.These were developed into 25 primary items with 30 follow-up items to present to the project team for discussion, removal, re-wording and ordering into sections based on categories.For example, because the term 'health promotion' is not widely understood by sports club stakeholders and potential respondents to the NAT, the item: 'Which national ministries target HP policies in the sports sector' was re-worded: 'Does your country have a national ministry (or department) that is mainly responsible for supporting sports clubs to address health topics (social, mental, physical health; well-being; sustainability etc.) beyond sport participation?;If yes, please indicate which one(s)'.Some section names were modified and some items were removed due to comprehension difficulties.For example, 'Are HP determinants acknowledged and understood at the national, regional, local level?' was removed because it was decided that many respondents might not understand health determinants or implementation strategies to improve them.Consensus was reached from the project team on 11 sections after four iterative meetings.Sections included: Role of ministry or department; Policies; Communication; Implementation and Dissemination; Evaluation and Measurement methods; Sub-national-level policies; Funding and Coordination; Participative approach; Actors and Stakeholders; National sporting events; Case studies and HPSC-NAT implicated stakeholders (see table 1 detailing the evolution from original items to the finalized HPSC-NAT).
Step 3: online surveys Twenty-two participants responded to the survey (see table 2).Based on the Likert scale, all section descriptions and included items were understood.Through qualitative data collection, minor modifications were suggested, such as separating options for different ministries in Section 1 (i.e.separate the ministry of Education and Culture into two options) or replacing the word 'transport' with 'transportation'.In Section 2, several respondents suggested adding 'Unhealthy  What measurements or surveys are used to monitor the actions on these health topics?
Please briefly describe (50-100 words) how information gathered helps to plan future policies: Please briefly describe (e.g.50-100 words) how the gathered information helps to plan future policies: (continued)  sponsorships' to the checklist for policy objectives and adding age ranges for target populations.Respondents suggested adding the phrase 'in your opinion' when referring to actions supporting HP in sports clubs in Section 3. Two respondents mentioned that they would have to contact other people to obtain answers about funding sources and coordination methods in Section 7.For this reason, in Section 11 the project team added an item requesting information about additional people contacted to complete the audit tool.After adjusting for nonresponses, the top three sections ranked in order of importance to evaluate HP policy support in sports club were: Policies, Ministries or departments and Communication (see figure 2).
Step 4: in-depth interviews In total 8 of the 28 EU HEPA focal points participated in an in-depth interview (see table 2).One major comment received during several interviews was that many of the responses to items would be 'no' because they had not implemented HEPA policies yet-'the HPSC approach is not yet known therefore, policies regarding this are far off in the future'.Several of the responding countries mentioned that their government was still focussed on implementing physical activity policies in settings such as sports clubs.Therefore, their ministries were not in a position to focus on the broad vision of promoting health (i.e.social inclusion, nutrition, civic duty) beyond the immediate benefits of participating in physical activity through sport.In addition, several focal points commented that 'the government is more focussed on competitive sport and sustaining funding for sports federations rather than providing support for local-level sports clubs'.Several focal points mentioned that it will 'take time to differentiate HPSC from HEPA and SCforH since these two are already well-known'.Minor changes were suggested to the formulation of some items in Sections 2 and 11.In addition, two focal points mentioned that the tool would need to be available in the country's native language as many words, such as 'beyond' do not have a precise translation or the word 'training' may be misconstrued and would need to be replaced with 'education' in his/her native language.
Step 5: HPSC-NAT finalization Two final project team meetings were conducted to discuss the suggested changes from the online surveys and in-depth interviews.As no major changes were requested by the focal points, consensus was obtained on the minor changes required (see table 1).The timeline for completing the HPSC-NAT was also defined as 3-6 months, based on the seven-steps described in the tool's introduction.It is also suggested that the process of completing the tool be led by a national representative from the sport or health sector and repeated every 2-3 years.

Discussion
This NAT has been designed to enable a comprehensive review of existing national policies focussed on supporting sports clubs to address health topics beyond sports participation.It is hoped it will act as a springboard to develop inter-sectoral approaches, policies and action plans to encourage HPSC.An international project team undertook the process of designing the audit tool through a fivestep iterative approach incorporating both qualitative and quantitative data collection methods.An initial 269 items were identified.
With the help of experts in the fields of physical activity and sports, 41 items were validated and classified into 11 sections detailing specific policies that support the HPSC approach.The tool was finalized  Development of the HPSC-NAT i35 after nine meetings.Due to several comments highlighting potential issues with obtaining the information to complete the audit tool, a final section regarding implicated stakeholders was added.This will aid in future development of the HPSC-NAT by showing differences in collection methods, adding additional options or refining certain items.
As the HPSC approach is a relatively recent development, many countries are still unfamiliar with the concept and the promotion of health beyond PA is still not commonly integrated in sports club settings.Although the call of health-focussed policies in sports clubs is not new, 6 even HEPA and SCforH indicators are not fully employed at national levels. 32Therefore, national policies can aid sports clubs to develop their HP actions and further embedded into local communities.When speaking about sports clubs, most EU HEPA focal points emphasized that governments focus on the core business of sports provision and competition rather than the more complex concept of HP which is the basis of the HPSC approach and has been previously reported. 8When developing related policies, their focus is on promoting HEPA in various settings.For example, several focal points mentioned that their government ministries are still trying to implement physical activity policies and implicate sports clubs in this process.Additionally, although many focal points were aware of SCforH, they had little understanding of the HPSC approach including its promotion of physical, mental and social health and well-being beyond focussing on the healthenhancing benefits of a particular sport which is one of the core premises of SCforH. 27Therefore, HPSC is a settings-based approach focussing on HP within the specific setting of sports clubs and is therefore differentiated from HEPA which specifically focuses on promoting physical activity in all settings.Both of these are distinct from SCforH which focuses on health benefits sports participants gain from participating in a particular sport or sports club.
Previous research acknowledged that sports clubs need support to develop HP, being limited in resources due to their voluntary nature, 19 and that external stakeholders such as national governments and affiliated sports federations could provide funding, guidelines, training and advocacy for HPSC. 15,33,34The HPSC-NAT will help policy makers gain an overview of current government policy creation and implementation and leverage actions directly or indirectly to focus on local sports clubs.The process of monitoring government support to promote healthful policies has shown success in other domains, such as policies pertaining to food environments. 35With consistent use of this audit tool, it is possible to monitor country progress in developing national policies to support HPSC, compare regional differences in policy development and share knowledge on the health benefits obtained by implementing HPSC polices.
The multiple steps and rigorous methods used to create the HPSC-NAT were essential to produce an evidence-informed and contextually relevant tool to monitor HPSC policies at a national level.Having a project team of international experts, researchers and academics brought diversity to the development process 29 while using participatory research methods to directly involve stakeholders to develop the final tool added universal understanding of each section and increases the likelihood for adoption and usability. 36everal limitations to this study should be noted.First, although the rapid literature review produced over 250 initial indicators, more indicators may have been found through a more comprehensive systematic review.Second, the audit tool was created in English.This is not the first language of many countries in which it will be used and a translation process is required for further development.Third, an extensive pilot data collection and analysis using the HPSC-NAT would support more comprehensive testing of the usefulness and acceptability of this tool.Testing of the audit tool is currently taking place in two countries, Ireland and France, and planned for additional countries.
Completing a policy review using the HPSC-NAT will provide comprehensive overviews of current policies, strategies and action plans supporting HP in organized sports clubs at a national level.This will enable country-level surveillance to evaluate gaps between national policies and local-level implementation, monitor changes and development of supportive HP policies, compare government policies and share knowledge between sectors and countries.Identifying national policies will help sports clubs to set criteria for promoting health within their own setting and community.Many sports clubs are voluntary by nature and therefore need government action, resources and a support system to make sustainable HP changes.The HPSC-NAT can help build a solid knowledge base to 1 identify potential gaps and barriers, 2 learn from experience 3 monitor progress, 4 understand challenges for future policy framing and planning in this context and 5 build understanding of the HPSC approach.

Figure 1 .
Figure 1.Process of developing the HPSC-NAT provincial and municipal), Programme description Leader of the HPSC-NAT completion process: Name, Institute and Contact details HPSC-NAT implicated stakeholders Leader of the HPSC-NAT completion process: Name, Institution and Contact details Other team members of HPSC-NAT completion process: Name and Institute/ Organization Other team members of HPSC-NAT completion process: Name and Institute/Organization Explain the completion process: Month/year, Main steps and Comments Explain the completion process: Month/year, Main steps and Comments Please list the consulted experts for input on the HPSC-NAT: Contact person and Institute/Organization Please list the consulted experts for input on the HPSC-NAT: Contact person and Institute/ Organization a: Item deleted.b: Item added by the project team.

Figure 2 .
Figure 2. Section rankings by order of importance.Grey bars are mean rankings for each section.Range bars indicate the minimum and maximum rankings for each section

Table 1
Indicators formulated into the HPSC-NAT

Table 2
Demographic details for online surveys and in-depth interviews