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Abstract

Aims:

To review the barriers and facilitators that cross-sector partners face in promoting physical activity.

Methods:

We searched Medline, Embase, PsychINFO, ProQuest Central, SCOPUS and SPORTDiscus to identify published records dating from 1986 to August 2021. We searched for public health interventions drawn from partnerships, where the partners worked across sectors and their shared goal was to promote or increase physical activity through partnership approaches. We used the Critical Appraisal Skills Programme UK (CASP) checklist and Risk Of Bias In Non-randomised Studies – of Interventions (ROBINS-I) tool to guide the critical appraisal of included records, and thematic analysis to summarise and synthesise the findings.

Results:

Findings (n = 32 articles) described public health interventions (n = 19) aiming to promote physical activity through cross-sector collaboration and/or partnerships. We identified barriers, facilitators and recommendations in relation to four broad themes: approaching and selecting partners, funding, building capacity and taking joint action.

Conclusion:

Common challenges that partners face are related to allocating time and resources, and sustaining momentum. Identifying similarities and differences between partners early on and building good relationships, strong momentum and trust can take considerable time. However, these factors may be essential for fruitful collaboration. Boundary spanners in the physical activity system could help translate differences and consolidate common ground between cross-sector partners, accelerating joint leadership and introducing systems thinking.

PROSPERO registration number:

CRD42020226207.

Keywords

systematic review whole systems approach physical activity cross-sector collaboration public-private partnerships

Introduction

Systems thinking is slowly integrating into new public health agendas and policies, placing cross-sector collaboration at the forefront of resolving wicked and complex public health problems. What may help and what may hinder short- or long-term collaboration across sectors remains largely unknown and understudied.¹ The question of sustainability as well as the effectiveness of a systems approach also remains.¹ However, public health organisations and agencies are promoting cross-sector partnerships within a whole system as essential to decreasing sedentary behaviours and ensuring healthier future generations.^2–5 In previous systematic reviews of whole-system approaches in obesity¹ and public–private partnerships for promoting physical activity,⁶ it emerged that using systems approaches and cross-sector working for public health goals is still in its infancy. There is a lack of consistency in the language and definitions, and little understanding of how to navigate a whole systems approach in practical terms.¹

Partners from the public and private sectors may benefit from alliances as these can be used to initiate collective action and communication between different sectors within a system.⁶ Mapping tools such as systems mapping have begun to unveil a plethora of non-traditional partners that may have previously been excluded, capturing the wider context of promoting physical activity.⁷ Linking together potential new partners who can engage in solving complex challenges could prove useful, but there is a need for a deeper understanding of these prospective new relationships and the outcomes of such collaborations. The complexities of co-ordinating actions across different sectors are well documented, albeit sporadically, and tend to reflect a narrow, rather than a dynamic, definition of cross-sector partnerships.

We aimed to retrieve, analyse and summarise the published literature on cross-sector partnerships promoting physical activity. Furthermore, we reviewed the reported barriers and facilitators to cross-sector collaboration where the partners were working towards a shared goal related to promoting physical activity. As far as we know, this review is the first to include: (1) partnerships across diverse sectors (not just public-private partnerships), (2) the promotion of physical activity of any type, scope and level and (3) the link and relationship between the partners and sectors. In this article, we present the findings focusing on the barriers and facilitators to cross-sector collaboration in physical activity promotion, operating in different countries and settings, and with diverse populations and socio-political contexts. We hope to highlight the range of challenges and opportunities that practitioners face when collaborating across sectors and provide better guidance about navigating the common hurdles of spanning boundaries in public health.

Methods

The systematic review was led by V.K. with each stage peer-assessed by N.B. and D.C. The protocol was peer-reviewed by a systematic reviewer (S.W.) and an independent topic expert and researcher. The protocol for this systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines⁸ and was registered and published in PROSPERO (ID: CRD42020226207) prior to conducting the systematic searches.⁹

Information sources

All search strategies were piloted by V.K. and peer-reviewed by a systematic reviewer (S.W.) and two active members drawn from a cross-sector partnership in sport, physical activity and public health. We searched seven electronic bibliographic databases (MEDLINE, EMBASE, ProQuest Central, PsycINFO, Scopus and SPORTDiscus) to identify records published in peer-reviewed journals from 1986 to 18 August 2021. Additional records were retrieved by reference checking and citation tracking to find additional qualitative or quantitative data regarding the effectiveness, barriers and/or facilitators of the included partnerships. In our keyword strategy, we used words describing ‘physical activity’ and ‘cross-sector collaboration and partnerships’ (Supplemental material, File 1).

Inclusion and exclusion

There were no restrictions on language of publication. We included any population targeted by a cross-sector partnership promoting physical activity. We included records reporting local, regional, national and global partnerships promoting physical activity, if at least two of the named partners were not from the same sector. We did not filter or exclude for publication based on language and used the Google translator tool for any publications not written in English. We excluded expert opinion pieces, audio/visual data, newsletters, informal communications and multimedia (e.g. slide-decks) presentations at the stage of title and abstract screening. We expected interventions to fall into the following categories: collaboration, coalition building, and community organising, advocacy social marketing, and policy development and enforcement.¹⁰ We expected sectors such as health, sport, leisure, transport, environment, city planning/urban design, education or academia, tourism, recreation and civil society, or as public sector, third sector and private sector. Records retrieved during the database searches were screened for title and abstract by one reviewer (V.K.).

Screening process

V.K. ran the systematic searches, retrieved the records and screened the titles and abstracts and included those that seemed to fulfil the eligibility criteria. The full texts of eligible records were retrieved and assessed by V.K. (100%, n = 110) and S.W. (23%, n = 25). Disagreements were resolved through discussion until consensus was reached and the reasons for excluding records at that stage were recorded. Included records were critically appraised independently by V.K. (100%, n = 32) and S.W. (28%, n = 9). We scored the risk of bias using the CASP checklist¹¹ for qualitative or mixed-methods research studies and ROBINS-I¹² for quantitative primary studies (all authors). We did not exclude based on the critical appraisal findings, as to avoid excluding ‘low quality’ records that may still generate valuable qualitative insights.

Thematic analysis

V.K. extracted relevant data from the final included reports using a data extraction proforma which was peer-reviewed by the systematic review team (all authors). Extracted information from included records was inductively and deductively summarised using thematic analysis¹³ by V.K. In the first phase of analysis, V.K. read and re-familiarised with the included public health interventions and partnerships making draft notes of general observations and common trends in the context or relationships of the partnerships. In the second phase, V.K. inductively coded for the barriers, facilitators, impact and quantitative outcomes, geography, shared aim and length of partnership. After the initial codes, V.K. produced codes deductively using Clarke and Braun’s¹³ approach. V.K. met with N.B. and D.C. several times to discuss the codes and naming the broad themes, until consensus was reached.

Results

Screening

We retrieved 1628 records across seven databases, of which 690 were duplicates (Figure 1). We screened the title and abstract of 938 records and the full text of 110 records. We included 32 records in our final sample, all published in English. Additional records (n = 8) were retrieved from citation tracking and reference checking of the included records (n = 32), reporting 19 public health interventions.

Figure 1.

PRISMA 2020 diagram

Critical appraisal

We used the CASP checklist for qualitative (n = 19) or mixed-methods records (n = 12), and the ROBINS-I guidance/tool for the quantitative record (n = 1). Most records reported qualitative methods to a satisfactory level to be included, but some were missing information or missing transparency about the research methodology and limitations, and the relationship between the researcher, the funder and the participants. The records reporting mixed-methods research were scored using the CASP checklist as a guide and only the relevant qualitative data from these records were extracted for the purposes of this article.

Data extraction

We extracted data from the included records using a proforma (Supplemental material, File 3). The included records reported various types of public health interventions (n = 19) (Table 1): collaboration (n = 6), health teaching (n = 1), coalition building (n = 3), community organising (n = 2), advocacy (n = 1), social marketing (n = 3), and policy development and/or enforcement (n = 5), as defined in ‘The Wheel’ of public health interventions.¹⁰ The shared goal was to promote or increase physical activity in different ways such as improving the built environment (n = 3), community investment (n = 1), promoting active travel (n = 2) or active living (n = 4), increasing sports participation (n = 2), building system-level capacity (n = 7) and developing or implementing policies (n = 7). The partners and stakeholders operated in various organisations across diverse sectors including public health, sport, leisure, transport, environment, city planning / urban design, education or academia, tourism, recreation and civil society, or as public sector, third sector and private sector. Partnership working would in some cases be assisted by interlinking agents. These were described as backbone organisations, cross-linking agents or boundary spanners. Some examples are: an organisation serving as a link between academia and industry;¹⁴ individuals called care sport connectors tasked with linking social care organisations and sports organisations;⁴⁵ a ‘think-do’ tank engaging lenders with communities struggling to finance initiatives;¹⁵ a social marketing organisation engaging third-, private and public sector partners;^29,30 a partnership centre engaging diverse sector partners;^31,32 and a local council team brokering connections and limiting duplication within the obesity-prevention system.^40–42

Table 1.

Overview of the public health interventions (n = 19) aiming to promote physical activity through cross-sector partnerships according to the public health intervention type, the partners’ shared goal(s), the intervention’s target population and the partners’ sectors.

Public health intervention(s) (n = 19)	Type	Shared goal(s)	Population(s)	Partners
Clinton Extension and Public Health Expanding Community Teams (EPHECT) coalition¹⁴	Coalition building	To improve the infrastructure and increase participation in physical activity opportunities	Residents in Clinton County Kentucky USA	Backbone support organisation: FCS Extension, building coalitions with representatives from local public health department, public library, schools, healthcare providers, managed care organisations and insurance companies, faith-based organisations, the Parks and Recreation Department the Chamber of Commerce the fitness/wellness centre, social services agencies, the county judge office, and the senior centre and more
‘Fun ‘n FITchburg (FnF)’ partnership, Omaha and Douglas County partnerships, and the Neighborhood Health Improvement Strategy¹⁵	Policy development and enforcement	To promote physical activity through community investing strategies	Wider population USA	Financial Innovations Roundtable (FIR) and hospitals, funders, universities, non-profits, and government agencies
Pennsylvania Advocates for Nutrition and Activity (PANA)¹⁶	Coalition building	To build capacity to create environmental and policy changes related to nutrition and physical activity	Residents in Pennsylvania USA	Multiple public agencies, non-profit organisations, institutions of higher education, corporate interest groups that operate at the municipal, county, regional, and state levels
Active Living by Design (ALbD)^17–21	Community organising	To make it easier for people to be active in their daily routines through innovative approaches to community design, public policies, and communication strategies	Residents in 25 communities USA	Health sector and schools, parks and recreation, urban design, planning and transportation, community leaders, policymakers and decision-makers (i.e. elected officials, tribal councils, appointed officials), other government (i.e. housing authority, community or economic development, social services, public works, law enforcement), advocacy sector, business sector, media sector, community- and faith-based partners (e.g. neighbourhood associations, walking/biking clubs, little leagues, individual volunteers)
Healthy People Alliance (HPA)²²	Coalition building	To implement the Action Communities for Health, Innovation, and Environmental Change (ACHIEVE) to prevent and reduce prevalence of physical activity, nutrition, and tobacco use	Residents in Klickitat County USA	National Association of County and City Health Officials (NACCHO) and local health departments, non-profit organisations, faith-based organisations, businesses, conservation and environmental groups
Green Schools Travel (GST)²³	Health teaching	To promote the use of sustainable modes of transport to school, e.g. walking, cycling and public transport use	Primary and secondary school pupils Ireland	Government departments (e.g. Department of Transport, Department of Agriculture and Department of Education), NGO and school partners (parents, teachers, principal and students)
Active Transportation Partnership²⁴	Collaboration	To create a plan to promote active transportation. There were five broad goals including increasing walking and cycling, improving safe travel and building an active transportation culture in the city	Residents in a mid-sized urban city Canada	Multiple stakeholders from the city, health sector and non-health sector organisations
Scottish Green Health Partnerships (GHPs)²⁵	Policy development and enforcement	To raise awareness of green health, e.g. social prescribing and physical activity referral, across key policy sectors and to develop and strengthen links and referral pathways between health and social care and green health projects and providers	Individuals with an established disease Scotland	Lead partners were the National Health Service and the local authority of each area, with partners from leisure providers, the environment sector, the voluntary, community and third sectors
Joint Action CHRODIS PLUS National Programs²⁶	Collaboration	To support European countries to improve the prevention of chronic diseases as well as their management, by piloting and implementing innovative approaches that have proven to be successful in other countries or settings	Various Portugal, Lithuania, Italy, Finland, Denmark, Spain, Croatia, Iceland, Hungary, The Netherlands, Poland and others (n = 14)	Professionals from the healthcare sector, employment sector, patient organisations, public health and health promotion and more
Partnerships for a Healthier America (PHA)^27,28	Policy development and enforcement	To encourage industry to offer and promote healthier options (nutrition and physical activity)	Staff and children in child care centres USA	Partnerships for a Healthier America (PHA) and private sector partners such as Bright Horizons, Learning Care Group, KinderCare, and New Horizon Academy, Y-USA, Boys & Girls Clubs of America (BGCA) and the National Recreation and Park Association (NRPA), US Tennis Association, Kaiser Foundation Health Plan
ParticipACTION^29,30	Social marketing	To promote physical activity through social marketing, communications, and partnership synergy	Various (mostly children and youth) Canada	ParticipACTION (backbone support organisation) and national, provincial, and local organisations: governmental, not-for-profit, private sector
Australian Prevention Partnership Centre^31,32	Collaboration	To develop systems approaches for the prevention of lifestyle-related chronic diseases	Wider population Australia	Researchers, policymakers and practitioners from education, government and third sector (charitable organisations)
National Physical Activity Plan (NPAP)^33–37	Policy development and enforcement	To develop and launch the NPAP to inform further development of state and community-based physical activity plans within the US (Bornstein 2014, Evenson 2014) To implement and adapt the NPAP in West Virginia (Elliott 2014, Abildso 2016) and San Antonio (Esparza 2014)	Wider population and Residents in West Virginia, and San Antonio USA	Public and private sector organisations/academies, alliances/associations/societies/club. Education, business and industry, healthcare, parks, recreation, fitness, and sports, public health, transportation, land use, community design, non-profit and volunteer organisations, policy and community representatives (San Antonio)
State Obesity Prevention and Control Programs³⁸	Policy development and enforcementz	To prevent and control obesity and other chronic diseases by supporting states in the development and implementation of science-based nutrition and physical activity interventions targeting all levels of socioecological influence	Residents in selected states (n = 28) USA	Universities or colleges, county and municipal health departments and medical centres or hospitals, school districts, American Heart Association. state dietetic association, parks and private sector
EPODE-derived Intersectoral community Approaches towards Childhood Obesity (IACO)³⁹	Collaboration, social marketing and advocacy	To address obesity determinants on the micro (child), meso (family) and macro levels (community context), thereby accounting for the multifactorial aetiology of childhood obesity.	Youth and children The Netherlands	Healthcare, welfare and sports, educational and private sector
Obesity Prevention and Lifestyle (OPAL) program^40–42	Collaboration	To prevent childhood obesity using systems-wide approaches and to increase healthy eating and active living in children	Children Australia	Local government (mayor, councillors, CEO, planners, community services, library), non-government organisations, local businesses, health, education, early childhood, state government (housing, police) and community members
Active city (pseudonym)⁴³	Social marketing	To have all citizens make regular physical activity part of their daily lives, through strategic marketing campaigns	Local residents Canada local	Community-based sport and health sector partners
Antwerp Community Sport Program (CSP)⁴⁴	Collaboration	To increase sport participation rates and physical activity levels	Disadvantaged communities in Antwerp Belgium	Antwerp Sports Administration and sports, social, health, cultural and youth partners
Dutch sport-for-health partnerships⁴⁵	Community organising	To increase sports participation of socially vulnerable youths, through care sport connectors	Socially vulnerable youth The Netherlands	Youth-care workers, representatives from community sports clubs, and care sport Connectors (brokers)

FCS: Family and Consumer Sciences; NGO: non-governmental organisation.

Thematic analysis

During the thematic analysis steps, we identified broad themes across the reported partnerships for what prevents (barriers) and what helps (facilitators) the collaboration between a variety of cross-sector partners. We categorised the barriers and facilitators into four overarching themes: approaching and selecting partners, funding, building capacity and taking joint action. Common barriers were funding insecurity, instability or insufficiency,^{17,18,22,23,25} passive engagement or intermittent partner representation and member turnover,^{17,18,29,30,32} collaboration capacity limitations or capacity misalignment,^{17,24,32,34,39,43} significant time commitment and low willingness for co-production.^29,32,33 Common facilitators were cross-linking agents that connected partners,^14,31,45 capacity and skills of potential partners being confirmed and agreed early on,^{17,22,31,40,44,45} diverse partners from different geographical regions,^17,26,35 clear and detailed expectations from partners and representatives, timelines and roles,^{15,17,26,31,34,38,45} transparency of true intentions and ‘buy-in’ or mutual benefits,^{16,26,35,37,38,42,44} using and sharing partners’ existing networks^{16,17,29,34,43} and building trust and leveraging support from partners.^14,17,25,44 Below we present detailed diagrams of the barriers and facilitators reported in the sample, organised by level (system, sector, partnership and partners) and theme (Figures 2 and 3).

Figure 2

Diagram showing the reported barriers to working in cross-sector partnerships by level (system, sectors, partnership, partners) and theme

Figure 3

Diagram showing the reported facilitators to working in cross-sector partnerships by level (system, sectors, partnership, partners) and theme

Discussion

Despite recent efforts to strive for whole-systems action for the promotion of physical activity, the process and impact of cross-sector collaborations and partnerships in such systems are poorly understood and sporadically documented. Understanding the relationships in such partnerships across sectors and developing recommendations of what works could accelerate the adoption of whole systems action. There are few systematic reviews about what works in cross-sector partnerships for promoting physical activity.

Jumping through hoops

Partnerships may be expected to operate inside the grey overlap area of sectors, industries, communities and populations and across different organisational missions and agendas. Orchestrating joint action across sectoral boundaries may burden the responsibility of sharing the lessons and impact of such collaborations solely to partners from academia that may wish to publish in journals, or to independent third-party agencies that may be conducting an evaluation that may be made publicly available. This may cause considerable delay in systems approaches being adopted, as the available evidence would remain widely uncaptured or unpublished. Whole systems thinking remains largely theoretical and/or conceptual in nature, so intentional data capture and sharing of lessons is often steered by government-led programmes and cross-sector partnerships which may require close monitoring and evaluation by an independent third party.²⁷ A recent review found that local evaluations of interventions, and access to funding and resources are important for implementing a whole systems approach to obesity and other public health areas.¹ However, partnerships that operate independently from the more traditional public and government orientated set-ups may struggle to find adequate funding or capacity to conduct an evaluation, or find it difficult to agree on how to measure their impact.^{17,18,22,23,25,30,45}

Collateral benefits and mutual inconvenience

The relationship between cross-sector partners naturally evolves as the partnership ages, as a working relationship is established, and trust is built. However, challenges such as finding common ground and restructuring activities so they align towards a shared goal, can often delay observing any impact. Evaluating the success and impact of any collaboration between sectors is dynamic and, in most situations, not pre-agreed. In fact, it has been suggested that the impact of cross-sector partnerships should include indicators of success that are familiar to non-traditional partners, for example, increased sports participation for sport sector partners ⁴⁵ and number of people using new bike paths²⁴ in the promotion of health behaviour choices like physical activity.

Sharing knowledge about harder-to-reach populations may also help some partnerships. One example, is a social care group that collaborated with a sports organisation and shared valuable insights, to guide the local sports programme in engaging vulnerable youths who were less likely to participate in sport.^44,45 Agreement of the shared goals and measurable outcomes early on in any collaboration may be essential for maintaining momentum and building trust, while avoiding conflict and delays. We found from our review that signing a partnership contract may not be sufficient to drive the partnership forward but may be a solution to setting clear roles and responsibilities, capacity and availability which, reported in our review, are major barriers to collaboration.^{17,22,31,40,44,45}

Finding partners who are willing and able to contribute to shared initiatives is an essential requirement at the early stages of collaboration. One example, is a project coordinator who was integral to the leadership of one agency’s involvement and had continuous oversight and invested interest in the partnership long-term, even when her role was concentrated elsewhere.¹⁷ Continuity of key partnership members promotes long-term momentum. Although current trends of whole systems thinking may spark the interest of professionals and organisations to respond to related public health agendas and funding, the question remains about the sustainability of those strategic intentions.

Current trends of systems mapping may lead to new combinations of partners but may also lead to blocking genuinely interested potential partners or even indirectly widening the health inequalities gap by a lack of representation or knowledge of the population of interest.¹⁴ More evidence on the tools and the outcomes from systems mapping is needed as it could help shape new combinations of partners in promoting physical activity.

Bees in a system

Boundary spanners may offer a solution by acting as the cross-pollinators within a dynamic and complex system, similar to bees in a garden. Active individuals, groups or organisations that may already view themselves as having a role in promoting physical activity or recruiting non-traditional organisations or groups that could contribute new knowledge may serve as boundary spanners.^31,45 Considering that the main challenges that partners face are related to the limits of time, resources and will to collaborate, boundary spanners may offer a flexible and dynamic, yet structured approach, to engaging the whole system.

However, it has been reported that one barrier for boundary spanners and backbone organisations is that fixed-term funding like grants may reinforce working in silos,¹⁵ possibly preventing boundary spanners to sustain and build on their role in the long term. Current guidance and (limited) evidence suggest that whole systems approaches require a shift towards holistic thinking and funding that is not solely based on quick surface-level impact.^1,2,4,5 More evidence is needed on how to evaluate the cross-pollination and therefore, demonstrate system-level change.

Limitations

It is worth acknowledging that this systematic review and thematic synthesis was conducted under several limitations, so we advise some caution when interpreting the results. First, some relevant records in the literature may have been missed due to the search strategy we used, which did not include terms such as ‘inter-disciplinary’ or ‘cross-disciplinary’ which may appear in relevant records but would have broadened our search too widely.

Second, the screening of abstracts and full texts, scoring risk of bias, data extraction and qualitative synthesis were predominantly conducted by V.K., a doctoral student. This was reflected in the scope and scale of the research window available to conduct the review and the significant role played by the main researcher. While it may have introduced greater opportunities for bias and/or errors during the various stages undertaken, we tried to mitigate this by introducing the use of a Systematic Reviewer (S.W.) and following a systematic review protocol, all necessary checks were implemented by a specialist (S.W.) to oversee screening and scoring bias, and the use of authors N.B. and D.C. to peer-review all principal stages and J.W. in the latter stages of the refining process.

Third, the content of the included papers may reveal some limitations in our sample which did not include an exhaustive list of partnership types and partner sectors that may be documented elsewhere in the literature. However, we included what we deemed as the most likely types and settings.

Finally, we included records that may have incorporated physical activity as a cross-sector partnership’s shared goal regardless of whether it was the main or secondary or the ‘add-on’ goal, which was found to be frequent in obesity-focused interventions. We acknowledge that these limitations may reduce the applicability of this review’s findings to some degree and to the types of partnerships and contexts included here.

Strengths

This is, to our knowledge, the first review to explore partnerships across a more diverse sample of sectors promoting physical activity of any type, scope or level and focusing on the relationship between the partners and between the sectors, as well as the barriers and facilitators faced by all within the whole system. Furthermore, the broader terms and concepts used in the keyword strategy compared to previously published similar reviews, demonstrate a balanced heterogeneity and similarity within the sample of included records and rich information provided in the records about the context of the partnerships. We included partnerships operating in different countries and settings and with diverse populations and socio-political contexts. It is the contention of the authors that these strengths have contributed to a more innovative review and a far more comprehensive review of cross-sector partnerships than has been previously reported.

Conclusion

Overall, our review resulted in themes around the limitations of time, resources and motivation of the cross-sector partners engaging in whole-systems approaches to physical activity. Boundary spanners may offer a solution to some of the challenges of cross-sector collaborations, boost local community efforts and continuously adapt to engage new partners supporting a long-term agenda. The deeper meaning of whole systems approaches remains largely unexplored with cross-sector working arrangements fluctuating between coalitions, community organising efforts, spontaneous collaborations or partnerships. In future research, the effectiveness of cross-sector partnerships and their true impact in the long-term should be investigated to update current and future guidelines for physical activity and systems thinking.

Supplemental Material

sj-docx-1-rsh-10.1177_17579139231170784 – Supplemental material for Systematic review of the barriers and facilitators to cross-sector partnerships in promoting physical activity

Supplemental material, sj-docx-1-rsh-10.1177_17579139231170784 for Systematic review of the barriers and facilitators to cross-sector partnerships in promoting physical activity by V Kolovou, N Bolton, D Crone, S Willis and J Walklett in Perspectives in Public Health

Footnotes

Conflict of Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. As a declaration of interest, the third author is a non-executive director of Public Health Wales (commenced 2021).

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article. This work was funded by the European Social Fund, KESS2 East Wales with support from company partners: Sport Wales, Public Health Wales and Natural Resources Wales (Case ID:82196).

ORCID iD

V Kolovou

Supplemental Material

Supplemental material for this article is available online.

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