key: cord-0771009-cuuoosgo authors: Menhas, Rashid; Dai, Jianhui; Ashraf, Muhammad Azeem; M Noman, Sohail; Khurshid, Sumaira; Mahmood, Sajid; Weng, Yu; Ahmad Laar, Rizwan; Sang, Xuehui; Kamran, Muhammad; Shahzad, Babar; Iqbal, Waseem title: Physical Inactivity, Non-Communicable Diseases and National Fitness Plan of China for Physical Activity date: 2021-06-03 journal: Risk Manag Healthc Policy DOI: 10.2147/rmhp.s258660 sha: 68340fdf0fdc23f40c75063e2d0006072b6593ed doc_id: 771009 cord_uid: cuuoosgo BACKGROUND: China has the world’s largest population, going under health transition due to industrialization, urbanization, and a sedentary lifestyle. About 82% of China’s disease burden is due to the prevalence of non-communicable diseases (NCDs). Physical activity (active travel) is the best preventive measure against NCDs. The Chinese government has introduced several steps to improve national fitness and overcome NCDs among the aging population. Exercise and sports play a vital role in promoting physical activity and helpful in accomplishing the national fitness level for Healthy China under the national fitness plan (NFP). OBJECTIVE: The current study aimed to explore the role of national fitness plan (NFP) in promoting physical activity and health well-being preventing NCDs under built environment intervention. METHODS: The study was exploratory, and the mixed-method approach was used to analyze the primary and secondary data. Quantitative content analysis was used to analyze the collected data. A purposive sampling technique was used to collect the primary data from those individuals rich in knowledge about the National Fitness Plan (NFP) of China and its role in promoting physical activity for physical fitness. RESULTS: The majority of the participants (32.0%) said that the national fitness plan helps promote sports environment and health. About 28.0% reported that NFP helps promote cycling and walk environments for physical activity and health promotion and preventing non-communicable diseases (NCDs). CONCLUSION: Participation in physical exercise and sports is the preferred approach to prevent different diseases. In the context of rising active living among the Chinese people, the facilities such as built environment and green parks under the national fitness plan (NFP) for sports play a crucial role in the mitigation of NCDs. Physical inactivity is a major contributing factor in global mortality. 1 It is estimated across the world that physical inactivity triggered about 20% of the disease burden from colon and breast cancers, about 6% coronary heart disease, and about 7% of type 2 diabetes. 2 An inactive lifestyle is a significant root of millions of preterm deaths worldwide each year and results from sedentary behavior. 3 Poor nutrition and physical inactivity are the main factors of death. 4 Disuse syndrome is the so-called result of inactive living. The prevalence of NCDs (depression, obesity, premature aging, musculoskeletal fragility, and cardiovascular vulnerability) is also the negative consequence of physical inactivity. 5 In high-income countries, the inactive citizens' ratio is growing (32% in 2001 to 37% in 2016), although it is stable at 16% in lowincome countries. Men in eastern and southeast Asia are found to be more active than women. 2 Physical inactivity is the fourth risk factor for global mortality, further impacting the prevalence of NCDs. Professional health bodies and the WHO have developed policies for the promotion of physical activity. The available evidence shows that physical activity intervention helps treat NCDs and improves the quality of life. 6 Physical inactivity is the 3rd leading cause of death. NCDs due to physical inactivity are the significant cause of increasing global mortality, and it can increase the death rate from about 20% to 30%. 7 Rapid urbanization and modernization in China are correlated with increasing sedentary activity and lifestyles. Between 1991 and 2006, the physical activity level decreased at an unprecedented rate. 8 The highest percentage of physical activity decline has been found in China compared to India, Brazil, the UK, and the US. 9 Environmental and societal changes have effects on the physical activity level of the population. In modern society, urbanization, increased use of motorized transport, and mechanization are the main leading factors of change in physical activity trends at the global level. Technological advancement impacts the levels of physical activity because it reduces a lot of physical labor. Sedentary leisure time has become attractive due to computers, cell phones, and electronic entertainment. In this paradigm, low-income countries are physically more active due to walking, cycling, and manual jobs. High-income countries are physically less active due to sedentary leisure recreations, which result from new technologies. Moreover, it is also estimated that middle and low-income countries will also reduce the physical activity level due to technological transition. 10 According to the recommended levels of physical activity, about 80% of adolescents (13-15 years old) are not achieving the target level across the globe. 11 In Chinese society, especially in cities, children depend on their parents for daily transportation and the growing trend of vehicle ownership, reducing the Chinese population's physical activity level. 12 National Physical Fitness and Health Surveillance 2010 of China indicated that about 77.3% of school-going adolescents failed to achieve the recommended level of physical activity. 13 China is an emerging world economic power and going through rapid modernization, urbanization, and economic growth. As rapid economic growth is happening in China, life expectancy is also increasing. In the modern and urbanized Chinese society, lack of physical activity, obesity, tobacco use, excessive alcohol use, sugar, and saturated fats, and excess salt has prevailed and further contributed to NCDs' prevalence. 14 The NCDs burden is expected to increase in both sexes from 2010 to 2030 in China among the aging population. 15 The development of NCDs among the aging population is the result of behavioral factors. The behavioral risk factors (physical inactivity, tobacco use, unhealthy diet, obesity and overweight, high blood pressure, dyslipidemia, and raising blood glucose) are essential biological factors for the prevalence of NCDs in China. According to the WHO, about 580 million Chinese were had one modifiable NCD risk factor in 2010. The biggest health threat is NCDs in China, and about 80% (10.3 million) annual deaths are happening due to NCDs. 16 According to the WHO, about 68.6% of the disease burden is NCDs. 17 CVD is the leading cause of death. In other diseases, cancer is about 4.1%, about 2.7% chronic respiratory diseases (CRD), about 12.8%, endocrine, nutritional and metabolic disease about 2.3%, and other diseases about 27.1%. According to the given statistics below, the burden of NCDs will be doubled among the Chinese people age group of 40 during the next ten years. The NCDs which are going to be increased in the next ten years are heart-related diseases, chronic obstructive pulmonary diseases (COPDs), myocardial infarction, lung cancer, and diabetes mellitus (DM). 18 20 To address physical inactivity and NCDs health issues, a comprehensive plan named "National Fitness Plan (NFP)" introduced by the Chinese government in two phases (2011) (2012) (2013) (2014) (2015) and (2016) (2017) (2018) (2019) (2020) . A substantial increase in the number of people engaged in physical activity is expected to occur within this initiative's context by 2020. 21 In promoting and meeting the Sustainable Development Goals of the United Nations, physical activity also plays a significant role. In response to health-related SDGs, the National Fitness Plan (2016-2020) and Healthy China 2030 were planned by the Chinese State Council. 22 The State Council has also made appropriate changes to the national fitness campaigns after the outbreak of COVID-19 in late 2019 and mandated newly developed communities to provide recreational facilities under regulations. According to the WHO, physical inactivity is the fourth risk factor for global mortality, further impacting NCDs' prevalence. Professional health bodies and the WHO have developed policies to promote physical exercise and sports for active living. The existing evidence indicates that physical training and sports intervention are valuable in treating NCDs and enhancing life quality. Sports and physical activity lead to a healthy society in many ways. Physical exercise enables a balanced lifestyle in the community through various other variables, such as the planned environment for physical exercise and sports. 23 Changes and construction of a sustainable built environment have a significant impact on sports and physical activity participation. The current study was designed to explore the role of national fitness plan in promoting physical activity and health well-being preventing NCDs under the built environment intervention. The National Fitness Plan (NFP) for the promotion of sports and physical activity among the Chinese population was implemented by the Chinese government to address the risk of NCDs. The National Fitness Plan (NFP) plays a critical role in encouraging exercise and sports among older adults and helps to achieve the national sustainable level of fitness by preventing NCDs. The environment in which physical activity and sports are taking place has a substantial effect on health. In developing countries, physical activity and sports have a significant contribution to the well-being of people. Sports, physical activity, and various kinds of exercise have long been used to treat NCDs. The current study used quantitative content analysis under the mixed-method approach in an open-ended form and conducted in Suzhou city, Jiangsu Province, People's Republic of China. The content analysis can be used in both qualitative and quantitative conditions according to the study nature and available resources. 24 The quantitative content analysis was used to explore the role of the national fitness plan in the promotion of physical activity and health well-being. The researchers employed a purposive sampling technique to collect the primary data from those individuals who are rich in knowledge about the National Fitness Plan (NFP) of China and its role in promoting physical activity for physical fitness. The study was exploratory, and the mixed-method research (MMR) 25 approach was used to analyze the primary and secondary data. The secondary source is General Administration of Sports of China surveys and the 6th National Sports Venues Census of China. The secondary data was both in qualitative and quantitative form. Only those secondary data were included in the study, which the government reported. Quantitative content analysis is one of the best exploratory research approaches to evaluate and understand the open-ended qualitative data form in its context. 26 It is a systematic and objective way of phenomenon description and quantification. 27 For useful content analysis, a prerequisite is that knowledge can be reduced to explain the research phenomenon. 28 The phase of abstraction is the stage during which concepts are generated in quantitative content analysis. A few features of the method may generally be easily explained. Still, it also relies partly on the researcher's intuition or analytical behavior, which can be very hard to explain to others. 29 The main steps of the quantitative content analysis performed in the study were designing, utilizing, sampling, recording, reducing, inferring and narrating. In qualitative research, purposive sampling is widely used. Only those key informants are selected who are rich in knowledge about the point of interest 30 to use limited available resources. Following is the eligibility criteria to participate in the study interview; (I) Know the national fitness plan (NFP) of China (II) Know the importance of sports and physical activity for health well-being (III) Know the importance of the built environment for sports and physical activity (IV) Participate in physical activity for healthwellbeing A total of 25 participants were selected through purposive sampling techniques in which 11 (44.0%) men and 14 (56.0%) were women. The demographic information of the participants is given below in the table. Data Collection Tool: An interview guide was used as a data collection tool in the current study. The nature of the interview guide was qualitatively based upon openended questions according to the study's objectives. The focus of the interview questions was knowledge about the national fitness plan, the importance of sports for physical activity and health-wellbeing, the importance of the built environment for sports and physical activity and participation in physical activity. There are several methods available to contribute to the formation of interview guides. Patton's 31 method is adopted in the current study to design the interview guide. Pre-testing of Interview Guide: A pre-testing was conducted of the interview guide on six key informants in the study area. Some questions were re-designed after the pre- testing, and some overlapping questions were removed from the final interview guide. Final in-depth Interview: Informed consent had been taken from the study participants after provided the study purpose information. The semi-structured in-depth interview was conducted face to face, and participant's responses were recorded in the written form. More than 45 minutes were spent for each participant's face-to-face in-depth interview. Data Quality Check: The member checking method was used to ensure the quality of the collected data. Debriefing or member checking is a method of returning and confirming the analytical results of the interview with the study participants. 32 This method also allows a new researcher to assess the data's quality in the best way. Surveys conducted by the General Administration of Sports of China and the 6th National Sports Venues Census of China were included as secondary data to achieve the study objective. Following are the sources of secondary data. The Chinese government introduced several laws to promote sport and physical culture for active and healthy living. The governmental laws were initiated to promote sport and physical activity across China. The Chinese government provided sport and physical exercise facilities at the community level to tackle the physical inactivity and NCDs problem among the Chinese residents. After implementing the policies, the General Administration of Sports of China conducted surveys to assess the mass sport situation in China. The surveys were conducted in the years 1997, 2001, 2007 and 2015. The built environment is an effective intervention to promote sport and physical activity among the nation. The Chinese government is also using the built environment intervention to promote sport and physical activity culture in China. The Chinese government started to construct playgrounds, green parks, walking trails and sports venues for global sports competitions. The 6th National Sports Venues Census of China was conducted to assess the status and situation of the sports venues in China. The primary data collected through the interview guide was analyzed through quantitative content analysis. The similar themes were categorized into four main themes based on the study participant's national fitness plan's knowledge. Categorization of the Role of the National Fitness Plan in the Promotion of Exercise (Physical Activity) and Health Well-Being Table 4 shows the categorization of the national fitness plan's role in promoting physical activity and well-being. Four main themes are sports environment and health, cycling and walking environment for physical activity, park use among the aging population and health promotion and prevention from NCDs extracted from the study participants' information collected through face-to-face interviews. Frequency of Each Type of the Role of the National Fitness Plan in the Promotion of Exercise and Health Well-Being (N=25) Table 5 shows the participant's responses to each type of role of the national fitness plan. The majority of the participants (32.0%) said that national fitness plan is helpful in the promotion of sports environment and health, about (28.0%) reported that NFP is helpful in the promotion of cycling and walking environment for physical activity and health promotion and prevent from noncommunicable diseases (NCDs) while only about (12.0%) said NFP is promoting the use of park among the aging population of China. Gender-Wise (N=25) Sports and physical activity are the catalysts of an active and healthy life. The Chinese nation participates in different sports and physical activities for active living after implementing various Chinese government interventions to promote sports and physical culture in Chinese society. Figure 1 shows the types of sports and physical activity which the Chinese people perform. In 1997, most Chinese people used to participate in running as an exercise. Most people used to play badminton, table tennis, ball games, and chess games in sports. Traditional Chinese sports also have a good impact on health, and Chinese people used to participate in the Thai Chi. In 2007, most Chinese people participated in aerobic and traditional Chinese sports such as yangko, ballroom dancing, broadcast, and qigong. In 2007, sports games and the long run were the most performed activities by the Chinese people. Sports and physical activity have various benefits and improve the HRQoL. The data statistics in Figure 2 show that about (72.32%) Chinese people participated in sports and physical activity with exercise in 1997. Almost (34.80%) people participated in sports to increase physical activity level in 2007, while about (35.60%) participated in keeping fit in 2015. Sports are a vital intervention as a preventive measure against physical inactivity and NCDs. The number of committees have fitness facilities. More than 90% of the developers in Guangzhou take sports facilities as one of the key selling points of the community, and the construction of sports facilities in the commercial, residential community is essential. There are 237 sports venues in 6 communities in Wuhan. Xi'an has 48.37 sports venues per 100,000 people. Macao currently has 2937m 2 of sports venues, and the per capita sports venues have increased to 0.63m 2 . According to the population of 21 million in 1999, Taiwan has an average of 300 stadiums per 100,000 people, which has caught up with or even surpassed some developed sports countries in Europe and the United States. Taking Beijing as an example, the per capita activity area will reach 1m 2 by 2005 and 1.1m 2 by 2010. It is necessary to build another 1.382 million m 2 of rural and urban areas in Beijing to meet the needs of public fitness activities. At present, there are 13,847.3m 2 venues for every 10,000 people in the outer suburbs of Beijing. The project covers the streets, harbors, parks, squares, communities and neighborhood committees of 18 districts and counties in Beijing. 38 Distribution of the Formal and Informal Physical Activity and Sports Places Table 7 shows the distribution of the formal and informal places for physical activity and sports reported in the four time surveys of General Administration of Sport of China. [33] [34] [35] [36] In 1997, rural and urban Chinese residents used (29.4%) formal and (70.6%) used informal places for physical activity and sports. About Traditional national sports have significant importance in promoting physical activity and health well-being at the national level. Different ethnic groups of the Chinese people developed traditional national sports such as shuttlecock, dragon dance, cuqiu, lion dance, wooden ball, rubber band skipping, pearl ball, shuttlecock, and fireworks. All the traditional national sports are included in the national fitness campaign to promote active living. 39 Four main themes emerged after content analysis is discussed below. In developing countries, the rise in the prevalence of sedentary lifestyles is a significant problem. The foremost reason for the prevalence of NCDs is the inactive lifestyle. Participation in physical exercise and sports is the preferred approach to prevent different diseases. 40 The study results showed that most participants (32.0%) said that the national fitness plan helps promote sports environment and health. The phenomenon of lack of physical activity has been around for the last 15 years. The Chinese government implemented a National Fitness Plan (NFP) to improve the Chinese people's health through sports and recreational activities. Active and healthy living is promoting in Chinese society through physical exercise and sports, further preventing NCDs under the NFP. It also focuses on national fitness at the local level. In this context, local government in rural and urban areas shapes the ecology by using urban planning towards a healthy lifestyle. The provincial government focuses on investment in the urban infrastructure, promoting physical activity at an individual level. In China, an industrial sports revolution has begun promoting physical exercise and sports culture across the country. Physical activity and sports participation are not up to the mark in the rural areas of China. In this context, the SGAS introduced several projects named Xue-Tan Project, Township Fitness Project, and Farmers Fitness Project to provide sports facilities to the rural population. 41 The ambitious target of the NFP is to enlarge sports participation, perk up fitness, and raise awareness regarding healthy living. National Fitness Programs also concentrate on the rural areas of China. As stated earlier, about 570,000 villages across the country have access to the facilities, and only 50,000 villages remain that are not yet protected by the NFP DovePress initiative. Besides, by 2022 to 2030, the area reserved for sports stadiums will exceed 1.9 and 2.3 square meters, respectively. 42, 43 Cycling and Walking Environment for Physical Activity Daily routine exercises such as cycling, walking, and running can prevent developing the risk factor of diabetes, heart disease, strokes, and cancer. 44 Physical activity in the form of cycling and walking is active travel in people's daily lives, which has positive effects on health. Cycling and walking are considered active travel, and it is influenced by many factors such as built environment, socioeconomic characteristics, and individual's attitude. 45 About ( 49 Most Chinese older adults were pensioners who went to the park for routine exercise, Qigong, light gymnastics, and dancing every day early morning. In China's public parks, much equipment is installed for activity, and older people perform different exercises to make their lives healthy and energetic. 50 Traditional Chinese physical activities have numerous health benefits and cost-free. They are easily organized at the community and neighborhood level and can play an imperative role in promoting physical exercise at the local and national levels. 51 It is proved that the use of parks among older Chinese adults helps promote physical activity. As the physical activity level increases among the aging Chinese population, it would be beneficial to achieve Healthy China and sustainable development goals, essential to a healthier society. The biggest health threat is NCDs in China. About over 80% (10.3 million) annual deaths are happening due to NCDs. 16 According to the WHO, about 68.6% of the disease burden is NCDs. 17 between the environments (social/economic/physical), the ecosystem, and health. In the ecological model, the built environment, which includes a built environment, is crucial in influencing people's well-being. 52, 53 Therefore, urban designs for sports under NFP is promoting physical activity trend and promoting health well-being. Moreover, its recreational features, land-use characteristics, transportation systems (public transit, streets, bike trails, and footpath for walking) help promote physical exercise and play a dynamic function in building a healthy society. The fitness walk and jogging trend among the Chinese population are significantly improved after the implementation of NFP. Nationwide about 12,229 fitness trails in China and above (95%) provide 24 hours access for physical activity. 54 Physical inactivity is the leading cause of mortality globally, which has implications on the prevalence of NCDs. Environmental and societal changes have effects on the physical activity level of the population. The main drivers of the change for physical activity trend among the Chinese nation are urbanization, increased use of motorized transport, and mechanization in modern society. In the social, physical, and mental growth of men and women, physical exercise and sports are pertinent. Physical activity levels increasing among the aging Chinese population after NFP implementation, and it would help achieve a healthier Chinese society. It is proved that the use of parks among older Chinese adults has been increased after the NFP implementation, which helps promote physical activity. The designed urban environment for sports and physical exercise has a significant effect on the lives of the elderly population. Since the introduction of the NFP, the aging Chinese population has shown a notable trend in physical activity participation. Implementing the "senior playgrounds" strategy with physical fitness equipment among the aging population encourages physical activity. Besides, the active travel (walking and cycling) intervention also contributing to the promotion of physical activity among Chinese adults. Physical activity and health status have a linear relationship as physical activity increases and physical fitness and health also improved. The elimination of physical inactivity through the built environment would eradicate the major NCDs from about 6% to 10% and increase life expectancy. NFP, national fitness plan; NCDs, non-communicable diseases; WHO, world health organization; NPFP, national physical fitness program; HRQoL, health-related quality of life; NSVC, national sports venues census; M-KFTP, million-kilometer fitness trail project; SGAS, state of the general administration of sports. The ethics committee of Soochow University, Suzhou, People's Republic of China, approved the current study's research protocol. The study participants signed consent was received during the informed consent procedure. 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