Raising an Active and Healthy Generation

A Comprehensive Public Health Initiative

Russell R. Pate; Marsha Dowda


Exerc Sport Sci Rev. 2019;47(1):3-14. 

In This Article

Implementing a Comprehensive Public Health Initiative

In the previous sections, we summarized a series of strategies for promoting PA in children and youth. For each of the strategies included, research evidence supports the strategy's potential for increasing PA, and experience in translating the strategy to broad application exists. In theory, any one of the strategies could produce, in a given child, the increase in PA needed to enable that child to meet current PA guidelines. But in practice, and when applied at the level of a community or society at large, it is very unlikely that any one strategy would generate the desired outcome. Rather, in our view, it is much more likely that a nation, region, or state will need to implement multiple strategies to move population-level PA to the desired level. Such an approach is consistent with the Social Ecological Model that was summarized earlier in this article. Furthermore, we believe that, to be successful, the strategies should be implemented in the context of a well-planned, coordinated, adequately resourced, and sustained comprehensive public health initiative. The characteristics of such an initiative are presented hereinafter.

Coordinated Planning

It is possible, perhaps even likely, that the individual strategies described previously will be implemented as the result of organic developments supported by advocacy groups committed to specific initiatives. For example, groups dedicated to expanding school recess might focus only on that activity, and the same would be true for different groups interested in improving the quality of afterschool programs. Indeed, we believe that this type of advocacy will be essential to moving the strategies forward. However, we also believe that progress toward attaining the overall goal of increasing children's PA at the population level would be accelerated by coordinated cross-sector planning at the national, state, and local levels. In the United States, this approach is represented by the National Physical Activity Plan, which is composed of evidence-based strategies, tactics, and objectives for promoting PA through initiatives in nine societal sectors.[105] Some states and local regions also have developed analogous PA plans.[106] Because most of the critical strategies for promoting PA in children and youth operate at the community level, we strongly endorse development of local planning groups that will focus on mobilizing community resources for promoting PA through actions in multiple sectors of society.

Focus on Equity

Compelling evidence indicates that there are marked disparities in PA levels of children and youth across population subgroups. It is well documented that, at all ages, girls tend to be less active than boys, and it is clear that PA decreases with increasing age, such that adolescents are much less active than younger children.[4] Furthermore, disparities in PA have been noted across race/ethnicity groups[107] and across children and youth categorized on the basis of family socioeconomic status.[108] In addition, it has been documented extensively that children's access to PA programs and physical environmental supports for PA vary markedly across socioeconomic[109,110] and physical ability/disability groups.[111] This has been shown for access to quality school physical education programs,[112] community-based PA programs,[109] and physical resources such as parks, green spaces, and sidewalks.[110] Clearly, in the United States, the playing field is not level for all children and youth.

Elsewhere in this article, we have noted some important actions that have been aimed at reducing PA disparities. These include Title IX, which has had an enormously positive impact on girls' access to sports programs,[98] and the ADA, which has produced important benefits for young people with a wide range of disabilities. However, research on PA interventions has yielded mixed findings regarding their effectiveness with children from disadvantaged backgrounds or minority race/ethnicity groups. Based on an umbrella review, Craike et al.concluded that interventions improve PA in children from deprived settings.[113] In contrast, the Healthy Communities Study found that community programs and policies to promote PA in children were associated with higher levels of PA only in children of non-Hispanic ethnicity.[114] This experience suggests that special efforts will be needed to design and implement public health interventions that are effective at reducing disparities in PA across age, race, ethnicity, and socioeconomic groups of children and youth.


Surveillance is a core function of public health, and it involves systematic collection of data for the purpose of designing, evaluating, and modifying public health promotion programs.[115] In the United States, systems for surveillance of PA levels in youth have existed for several decades. The Youth Risk Behavior Survey provides information on self-reported PA in high-school students on a biennial basis,[37] and the National Health and Nutrition Examination Survey has used accelerometry as an objective measure of PA in children and youth on several occasions.[4] However, large gaps exist in our overall youth PA surveillance system. These include limited monitoring of children at the middle- and elementary-school ages, inconsistent application of objective monitoring methods, and very limited assessment of programs and policies that influence PA in youth. Aside from regular assessment of school physical education policies[38] and participation in interscholastic sports programs,[38] we currently know little about the availability and penetration of PA policies and programs.[116] We recommend that surveillance systems be expanded and modified to provide for a much more complete and granular monitoring of PA levels and community-level availability of policies and programs to promote PA.

Capacity Building

Efforts to establish a robust public health system for promoting PA should learn from public health initiatives that are already well established. Two areas that are far more established than PA are tobacco control and nutrition. For both tobacco control and nutrition, the effort to build public health capacity began decades ago and has borne considerable fruit. For tobacco control, research and advocacy efforts that began in the 1960s with the release of the first Surgeon General Report on Smoking and Health[117] have produced regulations that ban the use of tobacco products in many settings, large-scale public health education campaigns focused on health risks of tobacco use, and taxation policies that limit access to tobacco products.[118] The U.S. federal dietary guidelines were first produced in 1980, and large-scale federal programs to reduce the prevalence of hunger and food insecurity are supported by enormous federal investments that are managed by a highly developed infrastructure that reaches essentially all schools and communities in the country.[119,120] If we are to have the same level of success in promoting PA that we have had in fighting hunger and reducing tobacco use, we will need to build the capacity for public health action that exists for these other behaviors.


One of the most notable assets of the PA/public health community is the extensive catalog of relevant resources that have been established in communities across the country. As applied to children and adolescents, these existing resources include school sports and physical education programs; school-based PA facilities; parks and community recreation programs; youth services organizations that provide afterschool, summer, and childcare programs; youth sports organizations; faith-based organizations that provide youth programs; and health care providers, particularly pediatricians and family medicine physicians. It is enormously important that these resources exist, albeit at widely varying levels, in almost all communities in the United States. Nonetheless, new resources are needed to fully and effectively mount a comprehensive public health effort to promote increased PA levels in the population of children and youth. These resources are needed for two major purposes. In most sectors, existing resources are not currently being invested in ways that optimize the impact on children's PA. For example, both school physical education and youth sport programs provide important opportunities for children to be physically active, but neither has been focused traditionally on optimizing participants' activity levels during program sessions. Likewise, afterschool and summer youth programs often do not prioritize providing PA. In addition, health care providers rarely have adopted systems for assessing and counseling children and parents regarding PA.

In all of the cases cited, the necessary infrastructure exists, but the existing assets need to be redirected to optimize children's PA. New resources will be needed to affect that redirection of those assets. Often the new resource would be invested in training and retraining of personnel. For example, in many instances, teachers, recreation specialists, youth sport coaches, providers of youth services, and health care providers need training in how to deliver state-of-the-art approaches to providing PA to children. In other cases, investments are needed to install new systems or provide physical resources that are required to support a new strategy. For example, if a youth PA program is to be modified so that most participants are active most of the time, sufficient space and equipment are needed to enable that strategy.


Building the capacity, establishing the surveillance systems, creating the plans, identifying the resources, and implementing the policies and programs needed to increase population-level PA in youth will require leadership. The effort will require leadership in all sectors and at multiple levels. Given the complexities of PA behavior, no one entity can or should "own" PA promotion at any level or in any sector. Strong leadership at the national level is needed to draw attention to the issues and is essential to implementing some of the recommended strategies. For example, designing and delivering a national media campaign on youth PA would require support from the national government, nongovernment organizations, and private sector entities. However, most of the strategies recommended in this article operate at the community level. Likewise, most of them operate within a specific societal sector. Consequently, strong leadership is most needed at the community level and, ideally, would include leaders representing multiple sectors. An attractive model is a community-level coalition that includes participation from schools, recreation commissions, faith-based organizations, health care providers, and youth service organizations. Public health agencies can play the important role of creating and managing such coalitions. Many leaders are needed, and they will be most effective when they work together in a coordinated effort.