Social Theory & Health

, Volume 15, Issue 4, pp 448–464 | Cite as

Communicative validity of health-related promotion of physical activity: A critical analysis of national health strategies

Original Article

Abstract

Presently, the promotion of physical activity (PA) is a core objective of global health governance. The question “How valid are communications concerning the health-related promotion of PA?” is thus assessed here. Against the background of Habermas’ critical theory (The Theory of Communicative Action. Reason and the Rationalization of Society. Boston: Beacon Press, 1984), the article examines health strategies for the promotion of PA by checking for violations of validity and pathologies therein. Through qualitative content analysis (Mayring in Qualitative Content Analysis: Principles and Techniques. Weinheim: Beltz, 2003), twenty documents concerning PA promotion issued by the ministries of health of the USA, Germany, Sweden, and Italy were considered. The following issues were disclosed: (1) comprehensibility: definitions of key terms are rare and recommendations on PA are somewhat ambiguous and contradictory. (2) Sincerity: there is a discrepancy between the utopic goal of the health promotion and the narrow preventive aims of the documents. (3) Legitimacy: some argumentations blame the population for being inactive, enhance the power of medical staff, and diminish that of other experts in this context. (4) Truth: occasionally, scientific knowledge is used in misleading ways, lack of evidence is disregarded, and alternative solutions are encroached on. Ultimately, the underlying mechanisms of these violations of validity and pathologies, their consequences, and the opportunities to overcome them are discussed using Habermas’ critical theory.

Keywords

physical activity health strategy critical theory validity claims 

Introduction

In recent decades, ways of living have radically changed around the world. This transformation was caused by an inextricable mix of socioeconomic, technological, and environmental aspects (Astrand, 1994, p. 101; WHO, 2016b). The positive trend of key health indicators demonstrates that these changes have had a beneficial impact on health overall. However, the increased use of passive modes of transport, urbanisation, changes of preference regarding leisure time activity, and other transformations have simultaneously decreased the levels of physical activity (PA) among the population. PA is here broadly defined as “any bodily movement produced by the skeletal muscles and resulting in a substantial increase over the resting energy expenditure” (Bouchard and Shephard, 1994, p. 77).

From a biomedical perspective, this drop has serious health consequences, because physical inactivity is one of the main risk factors of several non-communicable diseases (NCDs) which are currently the leading cause of death worldwide (Lee et al, 2012). Moreover, PA has proven beneficial effects not only in the prevention, but also in the treatment and rehabilitation of heart diseases (Williams, 2001; Do Lee et al, 2003; Sattelmair et al, 2011), cancer (Wolin et al, 2009; Speck et al, 2010; Ibrahim and Al-Homaidh, 2011), and diabetes (Tobias et al, 2011; Umpierre et al, 2011; Avery et al, 2012).

Against this background, the promotion of PA has been a key health political issue during the last decades. The issue of physical inactivity and how it can be fought through health promotion policies has also been widely investigated within the scientific community (for example: Sallis et al, 1998; Schilling et al, 2009; Rütten et al, 2013). However, these studies are mostly aimed at understanding what determines the success or failure of PA promotion, integrating the latest scientific findings into health strategies, and evaluating their impact on health.

These are certainly highly relevant issues. Yet the health-related promotion of PA entails plenty of other relevant sociological matters, which have been only partially explored. In particular with respect to critical issues, research on this topic has been principally carried out and interpreted through the Foucauldian concept of “biopower” (1998). Sound critical descriptions of PA promotion were carried out from this perspective by Deborah Lupton (1995, 1996, 2012), among others (Petersen and Bunton, 2002). Nevertheless, critical discourse on the health-related promotion of PA may profit from a broader theoretical differentiation. Notably, at the time the author composed this article, no comprehensive examinations of communications for the promotion of PA using Habermas’ critical theory (1984) were found. However, his concepts have already led to critical engagement in the scientific community concerning medicalisation and medical expertise (Scambler, 2001), and would be suitable for considering PA promotion as well.

Against this background, the present article critically examines a catalogue of health strategies issued by the ministries of health of the USA, Germany, Sweden, and Italy. The contents of these documents will be used as empirical material to assess a socially relevant set of questions, such as: How valid are health strategies for the promotion of PA? How comprehensible are they? How sincere are they? How legitimate are they? How truthful are they? Do they entail violations of validity and pathological communications? And, finally, how can their validity be improved?

Background

This section outlines the theoretical background (based on Habermas) which will guide the empirical analysis of national health strategies for the promotion of PA. Most concepts are borrowed from the two volumes of “The Theory of Communicative Action” (Habermas, 1984, 1985), which is considered his magnum opus (Finlayson, 2005, p. 16). In this work, among many other theoretical endeavours, Habermas proposed his celebrated distinction between lifeworld and system. The former term is the domain of shared understandings and a social horizon of everyday events, while the latter is the domain of scientific and technical interests, led by the rational logic.

This perspective considers the public health system to be a part of the social sphere of “systems”. Specifically, it is the department of the health system responsible for “preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts” (Winslow, 1920, p. 30). This article focuses on the promotion of PA, one of the main goals of health promotion, which is defined as “the process of enabling people to increase control over, and to improve, their health” (WHO, 2016a). In this context, the public health system openly aims to modify the lifestyle of the message’s recipients. However, PA behaviours are a classical lifeworld domain, which emerges from people’s cultural context, social relationships, and individual viewpoint (Habermas, 1985, p. 137). In other words, the health-related promotion of PA seems to be one of the societal fields in which systemic logic penetrates, or even colonises (Habermas, 1985), the symbolic reproduction of the lifeworld.

In order to understand how the system can penetrate the lifeworld, some basic concepts of Habermasian formal pragmatics need to be laid out: From this perspective, human actions are primarily coordinated in a conflict-free manner through communication. Normally, systems are homes of strategic actions: “Interactions in which at least one of the participants wants with his speech acts to produce perlocutionary effects on his opposite number” (Habermas, 1984, p. 295). Health strategies are one of the communication forms the health system can use to pursue its aims. These are here understood as official communications issued by a health organisation and aimed at purposefully addressing a topic related to health. The perhaps most powerful organisation of the health system, the World Health Organisation (WHO), defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO, 1948, p. 1). Although this definition has raised tough critique (Huber et al, 2011), it has also achieved the largest consensus, remaining a focal point of successive theories and definitions of health, and is still, most importantly, the operational definition of the health system (Hurrelmann, 2006, p. 119). As it is considered representative for analysing the concordance between the scope and contents of the communications examined, it will be used as a point of reference in this paper.

Health strategies for the promotion of PA aim both to inform and coordinate actions, but “the latter takes place when alter says `Yes´ to the validity claim ego raises with his utterance, that is, when alter responds affirmatively” (Habermas, 1985, p. 262). In addition, the health system lacks the necessary power to sanction any disregard of its message. Because the reader is theoretically free to accept or refuse the speech-act offer, and to “ground an agreement” (Habermas, 1984, p. 296), a mutual understanding concerning how to counter the problem of physical inactivity is needed in order to coordinate goal-directed actions (Habermas, 1985, p. 262). To achieve mutual understanding, the following four types of validity claims must be respected (Habermas, 1979b, p. 2)1:
  • Comprehensibility: This principle suggests that for the parties to develop understanding, their discourse must be mutually comprehensible. The documents analysed should be reader friendly, clear, transparent, sound, and explain the basis of the discourse, so the readers can understand what in fact is being communicated and why.

  • Sincerity: This principle refers to the degree to which participants in the discussion accurately represent their perceptions, interests, and openly represent. A communication offered sincerely and uttered in good faith does not try to manipulate, mislead, fool, or misguide the listeners.

  • Legitimacy: This principle requires a communication be appropriate, authentic, and respectful of the limits of the context within which it occurs. Conversely, illegitimate judgments cloaked as professional views, and attempts to take advantage of readers and other interested parties, are signs of illegitimacy.

  • Truth: The truth principle requires that all arguments presented in a discussion are factually correct and verifiable. In the case of health strategies, all key arguments should be scientifically based. Alternative theories and approaches should be openly and fairly presented as well.

If these claims are fulfilled, one can speak of an “ideal speech situation” and the requirements for mutual understanding are satisfied. In contrast, violations of validity claims imply a suboptimal communicative basis and may indicate that pathologies affect the communication. A communication is pathological if it confuses actions oriented toward understanding and success, or rather when it conceals a strategic action. Specifically, Habermas differentiates such cases between “manipulation”, a case in which “at least one of the parties behaves with an orientation to success, but leaves others to believe that all the presuppositions of communicative action are satisfied” (Habermas, 1984, p. 332), and “systematic distorted communication”, in which “at least one of the parties is deceiving himself about the fact that he is acting with an attitude oriented to success and is only keeping up the appearance of communicative action” (Habermas, 1984, p. 332).

Data and Methods

Through the theoretical framework described above, the validity of communications in health strategies will be examined by searching for violations which affect their comprehensibility, sincerity, legitimacy, and truth. From a methodological point of view, this article relies in part on the research programme of Forester (1982, 1993, 1999), which consists of a critical pragmatist approach to planning and policy analysis based on Habermas’ critical theory (Wagenaar, 2011, p. 293).

To create a relevant catalogue of national health strategies, a set of countries was chosen based on prototypes of differing welfare typologies (Leibfried, 1993):2 USA (Anglo-Saxon); Germany (Bismarckian); Sweden (Scandinavian); and Italy (Latin Rim). However, this paper does not focus on comparative aspects; this sample rather seeks to furnish generalizable results and narrow down the selection bias. For each of these countries, five national health strategies issued or sponsored by ministries of health were selected. The health ministry is the highest governmental department responsible for health and embodies the respective national manifestation of the WHO. Hence, an enquiry into the programmes of these organisations is particularly significant for a critical analysis of the discourse on the promotion of PA.

The appropriate documents for each case study were selected through a semi-standardised procedure, ensuring consistent and representative sampling. All health strategies were issued between 2005 and 2015 and aim to promote PA in general, while entailing a national scope. Documents which only occasionally assess the topic at hand were excluded from this study. The following overview contains the full list of items analysed:3 (Table 1).
Table 1

List of documents analysed

Nation

Document title

Year

Pages

USA

Physical activity guidelines for Americans

2008

65

Strategies to increase physical activity in the community

2011

50

Steps to wellness

2012

116

School health guidelines to promote healthy eating and physical activity

2011

78

National physical activity plan for the United States

2010

35

Germany

Advisor on health care

2010

120

IN FORM

2008

52

National health objective

2010

72

Mentally fit in old age

2010

40

Being active for myself

2010

52

Sweden

Action plan for diet and physical activity (Background Material)

2005

186

Healthy ageing a challenge for Europe – A Short Version

2007

36

Public health of the future – everyone’s responsibility

2010

32

The 2005 public health policy report

2005

18

Healthy dietary habits and increased physical activity

2005

24

Italy

National health plan 2006-2008

2006

100

National health plan 2011-2013

2011

123

Make gains in health

2007

44

Gaining health in 4 moves

2009

24

Pages of health

2009

16

These documents are a mix of strategic and informative communications on the promotion of PA from the perspective of national governmental departments for health and are relevant for understanding a facet of the ‘macro-level’ social structures which shape this context (Scambler, 2001). To explore the health strategies, the article uses the qualitative technique of content structuring analysis (Mayring, 2003, p. 89). This technique systematically identifies all passages that are relevant to answer the research question: “How valid are health strategies for the promotion of PA?” The collection, categorisation, and interpretation of these passages through the theoretical framework (Mayring, 2002, p. 115) enable an identification of pathological communications in the health-related promotion of PA. In particular, for each validity claim (Habermas, 1979b, p. 2; 1984, p. 39), a category for document analysis was created and examined through the following sub-questions: How comprehensible, sincere, legitimate, and truthful are the communications of health strategies?

Results and Interpretation

This section summarises the results for each of the sub-questions listed above and interprets them in the light of the critical theory. Passages from documents will occasionally be cited to exemplify the argumentations.

How comprehensible are the communications of health strategies?

In order to be perfectly comprehensible, the documents analysed should be reader friendly, clear, coherent, and furnish enough background to allow the reader a solid understanding of the reasoning behind the recommendations formulated.

The high complexity of the topic treated precludes the chance of achieving perfect comprehensibility. Communication disturbances are identifiable in the documents and can mostly be explained by the impossibility of supplying all the information required to fully understand the argumentations made (Habermas, 1970, p. 205).

However, the comprehensibility of the documents is limited by further issues, which are not directly connected with the above-mentioned complexity. First, the 20 documents generally lack the definitions of key terms concerning PA. For example, a definition of the difference between sport and PA is only once explained in one document (German Health Ministry, 2010a); four additional documents contain only the definition of PA (Swedish National Food Administration and Swedish National Institute of Public Health, 2005; U.S. National Physical Activity Plan Alliance, 2008; U.S. Centers for Disease Control and Prevention, 2011b, 2012); the rest of the documents lack clear definitions of these terms. This constitutes a relevant source of ambiguity, because sport is sometimes used interchangeably or as a synonym of PA, but it is actually a mode of PA characterised by being recreational, governed by rules, and orientated towards performance (Heinemann, 2007, p. 56). “Sport”, as an abstract term, is frequently mentioned in the health strategies, but the PA forms recommended are rarely commensurable with traditional-competitive sport activities or practicable in sport organisations. These latter activities tend to involve higher intensity, an on-average longer duration and a lower frequency than the PA recommended in the strategies. This deviates from the rhetoric of PA promotion of the 1980s and 1990s, which was largely based on traditional-competitive sport activities (Waddington et al, 1997).

In addition, the recommendations on the dose of PA are sometimes imprecise and discrepant. This inaccuracy is partly caused by the frequent use of ambiguous words like “regularly”, “everyday”, and “more”. These recommendations can be equivocal and are often too vague to constitute a beneficial suggestion on the dose of PA. For instance, saying that people should do “more physical activity”, a concept repeated more than 20 times alone in the document INFORM (German Health Ministry and German Ministry of Nutrition, 2008) and recurrently present in the other documents, is not only a vague recommendation, but also automatically implies that every PA already carried out by the reader is insufficient.

In spite of the acknowledged need of simple and concrete guidelines regarding the suitable form and quantity of PA (WHO, 2004, p. 8; Bauman and Craig, 2005, p. 3; German Health Ministry and German Ministry of Nutrition, 2008, p. 21), the strategies lack definitions, often use equivocal language, and are sometimes ambiguous.

How sincere are the communications of health strategies?

To be totally sincere, the health strategies should accurately explain and outline the motivation behind their aims. Furthermore the communications should be uttered in good faith, and not manipulate, mislead, fool, or misguide.

Contradictions regarding the strategies’ aims were detected. These issues regard the exchange between narrow and broad health goals and are a fil rouge throughout the argumentations of the documents. Indeed, the main goal of the health system is “the attainment by all people of the highest possible level of health” (WHO, 1948). However, this aim is only apparently pursued by the strategies, which focus almost exclusively on the prevention of key NCDs (WHO, 2008), such as heart diseases, diabetes, and cancer. This tendency can be identified in the recommendation of “30 min of moderate PA everyday” contained in most of the strategies. This recommendation is in fact unsuitable for reaching broader goals of health promotion, like: attaining physical fitness, which is “the ability to carry out daily tasks with vigour and alertness, without undue fatigue and with ample energy to enjoy leisure time pursuits and to meet unforeseen emergencies” (President’s Council on Physical Fitness and Sports, 1965, p. 5); managing medical conditions and illnesses which require more PA, like obesity and diabetes mellitus type 2; and fostering some psychosocial dimensions of health which can be better achieved through organised forms of PA, exercise, and sport.

In this way, the strategies are also misleading about the benefits of practicing “30 min of moderate PA every day” and fail to clarify which outcomes can be reached through other forms of PA and sport. The sporadic and nuanced modification of this “standard” in reference to population groups distinguished on the base of age, gender, or levels of PA is insufficient to solve this problem. Even though public health, by definition, cannot tailor interventions to individuals, the current dose of PA prescribed is evidently excessive for some, and definitely too low for many. A more differentiated explanation of the effects of different typologies of PA on the diverse dimensions of health would be more consistent with the aim of health promotion (Wheatley, 2005, p. 207).

This main contradiction exposes a pathological communication concerning the aims of the strategies: While national health systems purport to strive for utopic health goals for the world population, as defined by the WHO, they end up fixated on the narrow scope of preventing “merely the absence of disease or infirmity” (WHO, 1948, p. 1).

How legitimate are the communications of health strategies?

In order to be completely legitimate, the public health system should appropriately and authentically communicate according to the respective context. In particular, the public health system should not use its dominant position unfairly against other interested parties.

Concerning this validity claim, two distinct issues were detected. The first is related to coercive aspects of the health strategies which openly aim to influence people’s life(-styles) (Lupton, 1995) and “empower” them (Mishler, 1984). This logic puts the responsibility for one’s own PA at the level of individuals (Wheatley, 2005, p. 199) and thereby makes room for misleading moral assumptions concerning their lack of willingness and laziness (Crawford, 1977, p. 663). However, blaming individuals can be highly biased and unfair, because it dramatically downplays the role of the lifeworld’s domain, or rather of the cultural, social, and individual factors on PA behaviours. In this way, the (health) system colonises the lifeworld’s symbolic reproduction of PA by substituting it with a system of purposive-rational action dominated by the biomedical logic (Mishler, 1984, p. 77; Scambler, 2002, p. 55).

Second, the health strategies have a contradictory attitude toward the role and participation of the sport system in health promotion. On the one hand, the public health system declares the importance of cooperating to promote PA. On the other hand, it demonstrates a sport-hostile attitude by advising against traditional-competitive sport activities4 and downplaying the role of sport organisations and professionals. Particularly, the documents amplify the relevance of functions carried out by medical staff, in particular that of family doctors. Recommendations like ‘Before starting an intense physical activity, it’s a good idea to speak to your doctor’ (Italian Ministry of Employment Health and Social Policies, 2009, p. 5) can be found frequently in the documents of the four countries analysed (for example in: Swedish National Food Administration and Swedish National Institute of Public Health, 2005; German Health Ministry, 2010c; U.S. Centers for Disease Control and Prevention, 2011b). At the micro-level of doctor–patient interactions (Scambler, 2015, p. 364), this message may also increase the perceived authority of the doctor’s PA prescriptions.

Describing the health system as the centre of a network for PA promotion is here viewed as a pathological communication. Indeed, it strategically diminishes the legitimacy of sport as an alternative solution for the problem of physical inactivity. However, the sport system owns a capillary complex of organisations, whose main goal is implementing sport and PA programmes, which are often health related (Donaldson and Finch, 2012).

How truthful are the communications of health strategies?

In order to be truthful, all arguments presented in the discussion should be factually correct, verifiable, and scientifically based. Yet there are issues affecting the truth of scientific reasoning beyond the reasoning of the health strategies. From an epistemological viewpoint, scientific knowledge is irreducibly conjectural or hypothetical. As a consequence, any scientific theory, even one that which seems conclusively proven, can still be theoretically falsified in the future (Popper, 1965). This absolutely applies to the scientific research on the effects of PA on health, which is still ongoing and whose many assumptions are based on yet incomplete research programmes of different disciplines, like public health, epidemiology, sport psychology, and (sport) medicine.

Aside from these inherent limitations, scientific knowledge is sometimes used misleadingly in the documents. The fact that scientific evidence is misrepresented to support strategic aims has already been discussed in the previous sections. In addition, two further issues were identified.

First, the lack of scientific evidence concerning different sub-topics of health-related promotion of PA was not addressed. For example, although the negative impact of physical inactivity on health in adults is well documented (Warburton et al, 2006; Haskell et al, 2007), the scientific community is still debating the role of different PAs in preventing and treating a wide range of diseases (McDermott, 2008, p. 24). Moreover, there is even less research concerning its impact on the health of children (Janssen and LeBlanc, 2010) and older adults (Nelson et al, 2007). Finally, the relationship between the dose of PA and the optimal healthy response is a highly complex topic, which still has many desiderata (Kesaniemi et al, 2001; Samitz et al, 2011).

Second, the only form of PA which is strongly recommended is the moderate WHO standard. However, there is no definitive proof that alternative forms of PA are less healthy than a moderate option. This attitude is exemplified by the case of High Intensity Interval Training (HIIT): Recent findings conclude that the HIIT is a highly time-efficient form of training for healthy individuals (Gibala and McGee, 2008) and that it is better tolerated than moderate-intensity continuous exercise by patients with coronary artery disease and heart failure (Guiraud et al, 2012). Nevertheless, the strategies analysed never mention the HIIT as an example of suitable PA.

Recommending any mode of PA that is backed by reasonable scientific support (even if provisional) that fosters physical, mental, and social well-being and can reduce the risks of diseases would be more consistent with the goal of combating physical inactivity. A similar argumentation was identified only in some American documents (particularly in U.S. National Physical Activity Plan Alliance, 2008). These issues are further signs of pathologies affecting the communications of the public health system: They corroborate its strict focus on the prevention of diseases and its reluctance to incorporate findings from other scientific fields.

Concluding Discussion

The critical analysis of health strategies for the promotion of PA discloses violations concerning their comprehensibility, sincerity, legitimacy, and truth as well as the presence of pathological communications. Given the methodological limitations of the article, it is impossible to establish whether the identified pathologies are (conscious) manipulations or (unconscious) systematically distorted communications. Nonetheless, the discussion will focus on the causes and effects of these pathologies which affect the documents issued by national ministries of health.

The convergence of “neo-conservative ideology with right thinking common sense” (Howell and Ingham, 2001, p. 326) in the area of PA promotion explains part of the pathological communications identified. This ideology blames the “couch potatoes” for the state of their health and omits the fact that physical inactivity is “produced and systematically reproduced by forces and relations that individuals cannot wilfully control” (Wheatley, 2005, p. 215). Other pathologies seem to be rather related to the recent expansion of the health system into the area of health promotion: These communications aim to create and maintain authority in this area by emphasising the role of medical staff, by omitting the lack of scientific evidence and by encroaching on alternative solutions for the problem of physical inactivity. Additional pathological communications emerge from an internal contradiction within the logic of the health system, which still focusses on the prevention of diseases while aiming to promote health. Finally, pathologies seem also to be caused by the attempt of the public health system to substitute the old sport-based rhetoric of PA promotion with a new rhetoric, the content of which is not sharply defined as of yet.

While it is difficult to establish whether the disclosed violations of validity and pathologies negatively impact the battle against physical inactivity, they surely constitute an obstacle in reaching genuine consensus (Habermas, 1984, p. 301). Indeed, these issues indicate that a consensus on the promotion of PA can be only achieved if the readers do not recognise the existing communication disturbances (Habermas, 1970, p. 205). Yet basing the promotion of PA on a false assumption of consensus is dangerous (Habermas, 1970, p. 205), because violations of validity and pathologies, even minor ones, can never been totally concealed and their unveiling can harm the credibility of the entire message and even the accountability of the health system in this area. Resolving these issues is crucial for creating a message which is more consistent with ethical and pragmatic considerations (Finlayson, 2005, p. 142). Indeed, the commencement and establishment of a discourse on PA promotion guided by the biomedical logic and the medical experts’ knowledge is not intrinsically problematic, but some of these issues may lead to unfair moral judgements and cynicism towards inactive people and to an excessive colonisation of PA by the system (Mishler, 1984; Scambler, 2001).

The disclosure of violations of validity and pathologies affecting the communication in the health-related promotion of PA constitutes an opportunity to improve its validity (Habermas, 1970, p. 205; 1979a, p. xvii). Given the limited scope of the analysis, the high complexity and difficult manageability of the problem of physical inactivity, and the multitude of actors and interests involved, this contribution has very little chance to stimulate a re-discussion on the strategical approach to the promotion of PA. Nevertheless, the confirmation of these pathologies through further analyses may ultimately create the necessary visibility needed to become a topic for the health political agenda. Ideally, future studies should examine health system communications on PA promotion at different organisational levels through multi-methodological approaches. Following a suggestion by Edwards (2012), they should also focus on boundaries between lifeworld and system domains in the promotion of PA. This would enable an examination of conflicts in this area which encompasses interactions between individuals on the one hand, and the state, market, and health system on the other (Edwards, 2012, p. 34).

Notes

  1. 1

    This conceptualisation of the validity claims (Habermas, 1979b) has been extensively applied to empirical analyses (for example in: Forester, 1980; Yuthas et al, 2002). Later works of Habermas (1984) consider comprehensibility as the foundation of the other validity claims, because if an utterance is linguistically incomprehensible, then there is nothing to understand and assess.

     
  2. 2

    Gøsta Esping-Andersen’s (1990) classification of welfare typologies in liberal, conservative, and Scandinavian countries dominates the scientific discussion, but is also the subject of an ongoing debate (Arts and Gelissen, 2002). Leibfried’s (1993) proposal of including a fourth typology, namely the Latin Rim, is also currently widely accepted and applied in EU-sponsored analyses (Schmid, 2010, p. 107).

     
  3. 3

    The complete document references are listed in the bibliography. The Swedish health strategies were analysed in their English version, the German, the Italian, and the US documents in their original languages. Modified versions of this catalogue have been used in the previous works of the author (Michelini, 2015a, b).

     
  4. 4

    In particular, the public health system cites the following reasons for delegitimising sport as a medium of health (Michelini, 2015b): The disapproval of competition and performance as aims of PA; the superfluity of sport for being healthy; the dangers of sport; the impracticality of sport in comparison with everyday moderate PA.

     

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Copyright information

© Macmillan Publishers Ltd 2017

Authors and Affiliations

  1. 1.Institut für Sport und SportwissenschaftTechnische Universität DortmundDortmundGermany

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