Exploration of country-specific barriers and facilitators for the implementation of physical activity according to the EULAR physical activity recommendations for people with rheumatic musculoskeletal diseases in four different European countries: the COPA project

OBJECTIVES: Promotion of physical activity (PA) in individuals with rheumatic and musculoskeletal diseases (RMDs) is essential for disease management, yet evidence on social, environmental, and system-level determinants remains limited. This study aimed to quantify the prevalence of these determinants and compare them across four European nations. METHOD: A cross-country survey was developed based on a scoping review and semi-structured stakeholder interviews. The survey comprised 27 items across social, environmental, and system domains. Participants rated each item as a facilitator, barrier, or neutral, using a scale from - 10 (barrier) to + 10 (facilitator). Responses were analyzed to assess cross-country differences in demographic characteristics, PA behavior, and determinant ratings. RESULTS: A total of 734 individuals with RMDs participated (41.1% RA, 40.7% axSpA, and 18.1% OA) from France (30.5%), Switzerland (34.4%), the Netherlands (17.3%), and Turkey (17.7%). Significant between-country differences were identified in PA behaviors and demographics (p < 0.05). Overall determinant scores did not differ significantly (p = 0.101). Key facilitators varied across countries: "knowledge and fitness to perform exercises" was prominent in Switzerland; "scheduled exercises" in the Netherlands and France; and "health professionals" in France and Turkey. Common barriers included "weather conditions"-particularly in Turkey and the Netherlands-"costs of memberships or sport facilities," especially in France, and work-related duties in Turkey and the Netherlands. CONCLUSIONS: Despite comparable overall scores, the relevance of social, environmental, and system-level determinants of PA varied across countries These findings highlight the importance of country-specific contextual factors for understanding PA participation and for designing tailored, effective PA promotion strategies in people with RMDs. Key Points • This study provides novel cross-country insights by comparing contextual determinants across four European countries on how cultural norms and environmental infrastructures shape PA behavior in people with RMDs. • Context tailored promotion strategies may be crucial to increase adherence to PA recommendations and to make the implementation of policies more effective.