# 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

## TL;DR

This study compares factors that help or hinder physical activity in people with rheumatic diseases across four European countries, highlighting the need for country-specific strategies.

## Contribution

The study provides novel cross-country insights into how cultural norms and environmental factors influence physical activity behavior in people with rheumatic diseases.

## Key findings

- Key facilitators and barriers for physical activity varied significantly across the four countries.
- Common barriers included weather conditions, costs of memberships, and work-related duties.
- Tailored promotion strategies are suggested to improve adherence to physical activity recommendations.

## Abstract

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.

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.

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.

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.

• 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.

The online version contains supplementary material available at 10.1007/s10067-026-07984-5.