Health promoting sports federations: theoretical foundations and guidelines

Background Researchers and policy-makers have highlighted that the potential for organized sports to promote health has been underexploited. Sports clubs have limited capacity to promote health due to their voluntary nature and have called for support from their national sports federations. The present article provides guidelines, based on the theoretical principles of health promoting sports clubs and an analysis of practical tools and proven strategies, to support national sports federations to invest in health promotion (HP). Methods A qualitative iterative study was undertaken, based on five 2-h meetings of a group of 15 international researchers in HP in sports clubs. Notes and minutes from meetings, as well as shared outputs were analyzed based on the health promoting sports club framework. Results Guidelines developed for national sports federations to promote health includes a definition of a health promoting sports federation (HPSF), a description of how the settings-based approach to HP adapts to national sports federations, as well as practical applications of health promoting sports club’s intervention strategies. The analysis of existing tools also demonstrated that most tools are centered on a single dimension of health (social, mental, physical, spiritual or community), and often on a specific health topic. Furthermore, they do not cover HP as a continuous long-lasting process, but are generally short-term programs. The HPSF clarifies theoretical concepts, their practical implementation via case studies and outlines intervention components and tools useful for sports federations in their implementation of HP. Conclusion The guidelines developed in this study are intended to facilitate national sports federations to acknowledge/understand, reinforce/underpin and foster current and further investment in HP.

Background: Researchers and policy-makers have highlighted that the potential for organized sports to promote health has been underexploited. Sports clubs have limited capacity to promote health due to their voluntary nature and have called for support from their national sports federations. The present article provides guidelines, based on the theoretical principles of health promoting sports clubs and an analysis of practical tools and proven strategies, to support national sports federations to invest in health promotion (HP).
Methods: A qualitative iterative study was undertaken, based on five 2-h meetings of a group of 15 international researchers in HP in sports clubs. Notes and minutes from meetings, as well as shared outputs were analyzed based on the health promoting sports club framework.
Results: Guidelines developed for national sports federations to promote health includes a definition of a health promoting sports federation (HPSF), a description of how the settings-based approach to HP adapts to national sports federations, as well as practical applications of health promoting sports club's intervention strategies. The analysis of existing tools also demonstrated that most tools are centered on a single dimension of health (social, mental, physical, spiritual or community), and often on a specific health topic. Furthermore, they do not cover HP as a continuous long-lasting process, but are generally short-term programs. The HPSF clarifies theoretical concepts, their practical implementation via case studies and outlines intervention components and tools useful for sports federations in their implementation of HP.

Conclusion:
The guidelines developed in this study are intended to facilitate national sports federations to acknowledge/understand, reinforce/underpin and foster current and further investment in HP.

Introduction
Organized sports has largely been recognized and used by policy makers for its positive role as a powerful tool for the expression of political messages (1), and for facilitating wide-spread participation in sports and physical activity, with 12% of European citizens practicing sports in this setting (European Union, 2022). Research has also demonstrated that sport is a major contributor to the health of a nation (2). Specifically, evidence supports the contribution of sports participation to achieving international physical activity recommendations (3). Physical activity is largely recognized as a major health determinant (4,5) contributing to improved health outcomes preventing non-communicable disease and improving mental, social and physical health (6). Nevertheless, the White Paper on Sports (European Commission, 2007) and the Global Physical Activity Action Plan 2018-2030 (World Health Organization, 2018) have both underlined sports clubs' underexploited potential to promote health. Sports clubs have been defined as "private, non-profit organizations formally independent of the public sector, including volunteer members and a democratic structure, having sports provisions as their main aim" (7). Sports clubs could go beyond facilitating physical activity, by becoming health promoting settings (8)(9)(10) and by considering their potential to foster social, mental, physical and community health (11) However, evidence shows that this will not happen without support (12). The path to move from passive sports clubs providing physical activity opportunities to active health promoting sports clubs (HPSC) is long (13), represented as five stages in the settings-based approach to health promotion (HP) (14). Progressing through these stages requires formalized and systematic efforts, strategic focus and related marketing tactics to implement HP programs in collaboration with health actors (15). Indeed, the HPSC model calls for action on organizational (orientation, guidelines, policies and their implementation), economic (human and financial resources), social (vision, values and social norms in the club) and environmental (built environment and material) determinants of health at seven levels (from individual to policy makers) (16). In this regard, sports club managers expressed the need to have guidelines and support from their national sports federation (NSF) to implement HP (17)(18)(19), as programs promoting health through sports tend to be more complex than traditional sports development programs. This complexity is due to a need to deal with fundamental economic, cultural and health issues rather than a sole reliance on sports provision to achieve health impacts and outcomes (1). Sports clubs search for answers on appropriate methods to integrate multiple strategies on social, organizational, economic and environmental determinants across multiple health domains (social, mental, physical, spiritual, community) (20). In this regard, the application of the settings-based approach does provide a proper way to answer, even if HPSC implementation also face unintended health effects or may threaten the integrity of the organization (21), due to this complexity. For example, previous work has documented how sports clubs were confronted with a paradox in terms of feasibly implementing the safety policy, where stakeholders stated this policy was essential to ensure safe practice, but the cost to the club of its adoption would affect their ability to survive (22).
To date, research in this area has primarily centered on developing the HPSC model (16), and investigating how club managers and coaches promote health (23,24). Research on Australian interventions among community sports clubs have shown effectiveness on behavioral outcomes (25), as well as cost-effectiveness (26,27). Nevertheless, scant research has targeted NSFs (28,29), and focused principally on programs dedicated to health topics, such as, safeguarding children (30), doping prevention (31,32) and injury prevention (33). The presence, albeit limited, and the narrow awareness of HP as a global concept in international or NSF has been demonstrated (34), and its alignment to sports federation business is crucial for further investment (28,35). Such findings suggest a need to improve political lobbying, project and change management capacity within sports federations to develop HPSF (34).
To determine the theoretical and empirical gaps in HP in NSFs, the present article focuses on the creation of the Health Promoting Sports Federation (HPSF) Guidelines, to answer the research question: How to evaluate and foster health promotion implementation among NSFs? This article serves as a basis for the guidelines, by (1) offering a theoretical conceptualization of a HPSF, (2) providing evaluation indicators for a HPSF, (3) developing practical applications of the intervention components from the HPSC framework for NSFs, and (4) reviewing how existing tools to promote health are linked to HPSF.

Method Design
A qualitative, iterative design (36) was used to develop the HPSF guidelines, based on five steps: (1) defining a HPSF and applying the stages of the settings-based approach to HP a to NSFs, (2) creating HPSF evaluation criteria, (3) analyzing HPSF intervention components, (4) synthesizing tools supporting HPSF and (5) establishing HPSF guidelines.

Participants
This work was led by an international research group, also acknowledged as authors in the present article, under the 'Sports Clubs for Health' working group of the health-enhancing physical activity network of the World Health Organization Regional Office for Europe. A project team, composed of the three first authors and the last author invited 20 researchers worldwide, renowned for their contribution to HP in sports, to take part in five 2-h virtual meetings (February 16th, March 26th, April 26th, May 24th, June 21st). Participants gave their informed consent to take part in the study and were informed about the ethical implications of participating in the project, through an email in January 2022. Each participant engaged in at least three meetings, with a mean participation rate of 12 (min = 9 and max = 14) per meeting.

Data collection
The data was collected via feedback/notes and collaborative tools filled in by the first author during meetings, as well as by interactions and feedback through emails and an internal sharing platform between meetings. Agenda and minutes of each meeting were sent for approval, products generated from the meetings were shared for review and input from each participant was requested.
Step 1: defining HPSF and describing the stages of the settings-based approach to HP applied to NSFs To develop the definition of a HPSF, the research group established an initial definition of a NSF that delineates its interconnections with other sport organizations in the pyramid sport setting, such as international sport federations (umbrella organizations for NSFs worldwide) and sport clubs, as well as the different organizational structures (sub-national level and local level). Then, using the definition of the settings-based approach to HP and of a HPSC (37) as a basis, the HPSF definition was derived. Furthermore, the different stages of the settings-based approach (14,16) and the various descriptions of the relationship between sports and HP (38), which have previously been applied to sports clubs, were redefined in relation to NSF.
Step 2: creation of HPSF evaluation indicators Evaluation indicators were identified based on two activities; an initial brainstorming session on criteria that could help to inform how HP was developed in sports federations, before a working meeting to classify these indicators based on the four already defined determinants of health from the HPSC model (16): (1) organizational determinants (NSFs guidelines about HP including policies, rules and regulations are provided to affiliated sports clubs), (2) social determinants (NSFs vision, values and philosophy are in relation to those of society), (3) environmental determinants (NSF offers support for safe, supportive and sustainable infrastructure, green spaces and playing fields for affiliated sports clubs), and (4) economic determinants (NSF provides financial and human resources for HP to affiliated sports clubs).

Step 3: development of HPSF intervention components
The intervention components (i.e., actions to be undertaken by NSF to develop HP) from the HPSC framework (16), that were previously classified under the responsibility of NSFs, were selected to ground the present work in an existing theoretical model, the HPSF framework (16). The research group first created a template of information needed for NSFs to implement each component, and determined the following: (1) how they were linked with NSFs' previous experiences and actions, (2) what was the purpose of their implementation, (3) how they should be implemented according to the HPSF stages and (4) what role each stakeholder in the HPSC framework plays in its implementation. The template was discussed during two meetings, and then completed by the first author, with each component review by a member of the research group who had the highest level of expertise.
Step 4: review of tools supporting HPSF To select tools supporting HPSF, a systematic search was conducted on the Erasmus+ website, 1 using the keywords "health promotion" and "sports. " Inclusion criteria were: (1) to target HP or health topics in organized sports, (2) to include an English version, (3) to propose a tool (training, game, booklet, etc.) as an output, (4) to cover more than a single sport and (5) to constitute a practical document, not only policy recommendations. Exclusion criteria were (1) not targeting organized sports but physical activity in general, (2) no final tool availability in English language. An excel spreadsheet was developed for data extraction and circulated among the participants, to add details extracted from known tools based on the given inclusion criteria. When selected, the tool was fully reviewed by research group members, including website presentation, tool presentation and content. The review process for the tools was defined during two meetings. Meeting 2 focused on defining the templates for analysis using four categories: (1) description of the tool (weblink, language, link to HP, topic covered, date of release), (2) pedagogy of the tool (objectives, content, HPSF stage reached using the tool, person using and person targeted by the tool, type of tool, time estimated to complete and to implement, need for a trained person), (3) production and evidence (tool creation process, quality of evidence), (4) link with HP approach and theoretical framework (strategies of the Ottawa Charter and of the HPSC framework mobilized by the tool). Meeting 4 focused on discussing inclusion criteria for some tools where doubts had been expressed and adapting the template based on a review of the two tools. A double peer review process was undertaken on the chosen tools; a first draft analysis was produced for all tools by the first author and reviewed by a member of the research group.
Step 5: finalization of the HPSF guidelines All of the different work sections were compiled into a single document. The design was reviewed by research group members, as well as external sports and health experts, including three French sports ministry members, two project managers from the French Public Health agency and three representatives from NSFs (France, Sweden, Luxembourg). The use and dissemination strategy were reviewed by the research group members during their last meeting.

Data analysis
Notes and productions were analyzed by the first author using a deductive approach, based on the HPSC framework as a theoretical basis (16). The data analysis was conducted between each meeting, based on participants' answers, as well as on the minutes from meetings sent to the research team. The results and output from each step were sent again to the research team/participants. They could Frontiers in Public Health 04 frontiersin.org provide their feedback before or at the beginning of the next meeting. After the five meetings, all notes were collated and reviewed twice by the first author (to become familiar with the content and to verify comments to include in the final guidelines). The research team read the final product and provided feedback twice. This feedback has been considered in the final guidelines. Data validity was addressed by having all participating researchers validate the final version of the guidelines (ensuring triangulation and respondent validation). In addition, a cross-country comparison of the guideline's applicability was undertaken based on participants' experience (triangulation of context) and an iterative constructive process of including existing literature on HPSC at each level, as well as during the case study search. Finally, data reliability has been facilitated by ensuring appropriate wording was used in the guidelines, and through collective validation of the final version of this article.

Results
Step 1: definition of a HPSF and of the settings-based approach stages applied to NSFs The research group adopted the Institut National de la Jeunesse et de l'Education Populaire (INJEP; National Insitute for Youth and Popular Education) definition of sports federations: "National sports federations are responsible for planning and managing their sports at a national level, through an organization based on membership of affiliated clubs. A sports federation organizes and promotes the practice of it(s) discipline(s), from leisure activities to high level sports. " 2 This definition was considered as the most inclusive of all types of NSF, including non-Olympic ones, as well as including different types of sports practice. After brainstorming the different activities and processes in place in NSFs, a HPSF was defined by the research group as a "national sports federation that considers health in its values, vision and leadership, as well as in its activities and training" (see Figure 1 for details). There are two primary aspects of a NSFs focus towards becoming health promoting: "to be a health promoting sports federation" (considering health in all policies, decision making processes, structures and activities) and "to support their affiliated clubs to become health promoting" (invest in programs, guidelines, toolkits, human resources helping affiliated club to promote health). Moreover, the application of the five stages of the settings-based approach to health promotion (14) can offer insight to NSFs on how to progress towards becoming a HPSF (see Table 1 for details).

Step 2: creation of HPSF evaluation indicators
The research group created nine categories of HPSF evaluation indicators through brainstorming (engagement from NSF, HP policy implementation, dedicated training on HP, dedicated HP programs, 2 https://www.insee.fr/fr/metadonnees/definition/c1258 presence of safeguarding for members, presence of HP or prevention for (elite) athletes, financial investment, visibility, governance structure) and emphasized the need to ground them in a theoretical model (Ottawa Charter, Global Physical Activity Action Plan, HPSC model). For each category, work was undertaken to clarify the indicators, the questions used to evaluate them and the data sources an NSF could use. A final list of 18 indicators based on the four HPSC health determinants (nine organizational determinants, three environmental determinants, three economic determinants, and three social determinants; see Table 2 for details) were integrated into the HPSC model, which was approved during the second meeting. These indicators have been designed to work on the whole system of the NSF, impacting both policy framing and practice, as well as the decision-making process, as described in the settings-based approach to HP. Moreover, these indicators served as a basis for the case study analysis in chapter 2 of the guidelines (on case studies), and can be used as a self-evaluation grid to choose the strategies presented in chapter 3 (on implementation strategies) and the tools presented in chapter 4.

Step 3: development of HPSF intervention components
Intervention components were operationalized to support practice-based use. The final full description of each of the 26 intervention components can be found in the guidelines (Table 3 summarizes how each intervention component can be implemented by NSFs at each HPSF stage). The decision was made to retain the original formulation of the intervention components, as well as not to create a new one, to keep consistent with the HPSC framework and to develop a practical application of an existing theoretical model, rather than the creation of a new theory (Table 3). This work has raised the issue of describing actions that could be seen as an example to implement any health behavior and emphasize the progression from an individual change driver in a passive organization to an active organization fostering individual health and well-being. This question has been answered on choosing to either use the formulation mentioning a single health topic, which is limiting in regard to applying a holistic HP approach, or in choosing to use the umbrella concept of HP as a keyword for investment in multiple behaviors and health topics. Furthermore, as the intervention components belong to a strategy, we found the intervention components to be redundant, which was considered as acceptable, as NSFs will have to choose which to implement and will probably not target all of them at the same time.
Step 4: analysis of tools supporting a HPSF Among the 117,501 Erasmus+ projects identified between 2015 and 2022, 336 projects included both HP and sports as keywords. Sixty projects were collaborative partnerships (staff training and youth exchange projects were excluded because no tool was produced). Among the 60 included projects, 26 targeted sports organizations and provided links to outputs or tools, leading to their inclusion in this review. In addition to the 26, the members of the research group provided links to additional tools they had identified as relevant.
Frontiers in Public Health 05 frontiersin.org Eliminating duplicates and based on a full-text review, 28 tools were retained and presented in the guidelines. Reasons for exclusion of projects included: they were not directed towards sports federations (n = 7), tools were inaccessible (n = 4), content was not practical enough (n = 1), was not focusing on HP (n = 5), focused on a single sport (n = 1). Of the 28 tools, 16 were documents or leaflets, two were websites, one was a game, four were online trainings and five a combination of two or more types of tools (Table 4). Social health was considered in 13 tools, mental health in 12 tools, physical health in 8 and governance or capacity building in 5 tools, while 4 tools targeted more than one dimension of health action. Regarding the evidence used to build the tool, 18 were research based, 24 practice based and 5 built with stakeholders, whereas 3 tools included a combination of these. On average, tools targeted three of the five Ottawa Charter (39) strategies (n = 11 for building public health policies, n = 25 for creating supportive health environment, n = 18 for strengthening community action, n = 20 for developing personal skills and n = 8 for reorienting health services), where three covered all five strategies. On average, six strategies from the HPSC framework were developed in the identified tools (min = 1 and max = 13), with 16 based on planning, 17 on education, 18 on resources, 9 on feasibility, 11 on goals, 18 on mobilization, 8 on monitoring, 15 on participative approach, 17 on partners, 15 on communication, 11 on dynamic, and 8 on experience.
Step 5: finalization of the HPSF guidelines The final guidelines includes 151 pages, structured across four chapters: analyses and monitors HP in a NSF, is inspired by case studies and examples of NSF investment in HP, implements the HPSC framework, identifies tools to support HPSF and HPSC. The guidelines can be approached in different ways; however, it is recommended to proceed by reading the first chapter and application of the evaluation criteria and acknowledgement of the HPSF stage for the NSF. Then the case studies, intervention components and tools can be used to move on to the HP development in a sports federation, as each of them are linked to a specific strategy of the HPSC framework.

Discussion
The HPSF guidelines have been designed to clarify the theoretical concept of a HPSF and support its implementation Description of a HPSF.
Frontiers in Public Health 06 frontiersin.org through case studies, intervention components and tools. The guidelines are designed to act as a springboard for NSF to acknowledge, reinforce and further foster their investment in HP. This work is aligned with recent research efforts to clarify the theoretical tenets of a HPSC, as a previous literature review has shown that the application of the settings-based approach to HP has to be tailored to the context of the setting and core business (40) of the organization. For example, schools, universities and even cities have different characteristics compared to sports clubs (41), which are typically run by volunteers, have sports provision as their main aim, do not always own their facilities (13) and depend on NSF regulations, support and guidance (42). Moreover, a recent literature review showed a poor application of the settings-based approach in sports clubs, with programs principally targeting sports participants and lacking support for clubs to make organizational changes (8).
The HPSF Guidelines consider the four determinants of health: organizational, social, environmental and economic, and go beyond traditional education program for coaches or health information for sports participants (43), supporting the implementation of more complex HP programs. Another important aspect of these guidelines is that they constitute the first offer of theory-based intervention components to implement within NSFs, whereas previous studies have principally used observational studies or did not root their intervention in a theoretical framework. Nevertheless, no empirical data have been collected scientifically on the application of these intervention components, and there is a need to test their application and outcomes. In that regard, the creation of HPSF indicators, considering the whole system of a NSF, highlight key outcomes of the development of HP by NSF, therefore providing a first attempt for a self-evaluation tool for NSF. In line with previous publications on the HPSC model (44), evaluation indicators can help to clarify the resources, activities, outcomes and impact of HP development by NSF, and could help government authorities, and local sports clubs to clearly call on their fulfillment by NSFs.
The analysis of existing tools showed that most of them are centered on a single dimension of health (mental, social, physical, spiritual and community), that they are often on a single health topic and that they do not cover HP as a process, more as a short-term program, that in turn, does not support sustained improvement to the health of sports club members. These findings are similar to results found in sports clubs, e.g., in Australia only 3% of the sports clubs had a policy on multiple health topics (45). In France, a case study on 8 exemplary HP projects has demonstrated that each project targeted a single health topic (24). Interestingly, creating a supportive health environment was the most targeted strategy of the Ottawa Charter (39), where reorienting health services was the least implemented. There is a need to move from interventions directly targeting sports participants towards a whole system approach (46). In regard to creating public health policy, efforts are still needed in sport on policy development, having been acknowledged in research as the biggest weakness of sports clubs (47). In addition, creating a supportive environment is the Ottawa Charter strategy which is the most aligned to sports clubs most developed HPSC strategies, like mobilization, resources, partners and education, which are also linked to identifying financial and human resource support to develop HP. This is in line with a request from sports clubs, identified in a previous concept mapping study among French sports clubs  (14).

Stage
Core perspective Definition Action of national sports federation . A more challenging result concerns the few tools mentioning the experience and the monitoring of implementation strategies. The evaluation of HP in sports clubs is not undertaken nor encouraged in these tools, whereas previous work has shown that HP project managers in sports clubs lacked tools and methods to evaluate their actions (24) and a previous literature review has demonstrated the paucity of use of validated measurement to evaluate the application of the HPSC approach (8). As the settings-based approach is challenging to evaluate (48), robust methods to investigate the (cost) effectiveness of policy and practice at multiple levels, using multiple    strategies have already been used with health promotion interventions in sports clubs (26,27).
The developed guidelines will be published on the World Health Organization's website. NSFs can use these guidelines to establish appropriate governance to support HP and embed it in existing policies and practice, identify tools and examples to support affiliated sports clubs to invest in HP, develop programs supporting HP in and through sports and provide evidence that the NSF is playing an enhanced role in society.

Strengths and limitations
The rigorous method and multiple steps used to create the HPSF Guidelines helped to produce a theory based and evidence informed tool, offering the opportunity to develop multi-levels and multistrategies, in accordance with public health researchers' recommendations (49). Moreover, the final guidelines have been reviewed by 3 practitioners beyond the group, to facilitate a transfer into practice.
Nevertheless, several limitations to the present study should be noted. First, no new literature review on how NSF undertake HP was conducted to evaluate the current state of the evidence, as well as barriers and facilitators to its implementation. Second, the present guidelines is created in English, limiting its use and dissemination in some countries and most of the researchers involved came from Europe, possibly limiting its application to Asia, Africa or North America. Third, NSFs were only involved in the final proof reading (50), as no co-construction process was undertaken through participatory research.

Conclusion
The article provides theoretical foundations, analysis of practical tools and strategies to support NSF investment in HP. It    contributes to the development of HP in organized sports by providing a definition of HPSF, illustrating the application of the setting-based approach to HP to NSFs and providing intervention components linked with strategies in the health promoting sports club's intervention framework. The intervention components, guidelines and tools provide practitioners, including NSFs, clear and useful guidance on how to promote health. Future research needs to further evaluate the feasibility and acceptability of this theory based guidelines, their effectiveness in delivering health outcomes as well as their adaptability to different cultural contexts.

Data availability statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Ethics statement
Ethical review and approval was not required for the study on human participants in accordance with the local legislation and

Author contributions
AH, SG, AV, and MW have contributed to research design and method definition. All others authors have contributed to shared knowledge, toolkit evaluation, reading of successive version of the guidelines. AH, AV, and CW have secured the funding to generate these guidelines. All authors contributed to the article and approved the submitted version.

Funding
This project has received funding from the European Union's Horizon 2020 Research and Innovation Programme under the Marie Skłodowska-Curie grant agreement No. 101028401. This work was funded by a grant from the World Health Organization in partnership with Santé publique France, Université de Lorraine and Université Côte d' Azur.