ContentslistsavailableatScienceDirect
Health
Policy
jo u rn al h om ep a g e :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l
Promoting
health-enhancing
physical
activity
in
Europe:
Current
state
of
surveillance,
policy
development
and
implementation
João
Breda
a,∗,
Jelena
Jakovljevic
a,
Giulia
Rathmes
a,
Romeu
Mendes
a,b,
Olivier
Fontaine
c,
Susanne
Hollmann
c,
Alfred
Rütten
d,
Peter
Gelius
d,
Sonja
Kahlmeier
e,
Gauden
Galea
a aWorldHealthOrganization,RegionalOfficeforEurope,DivisionofNoncommunicableDiseasesandPromotingHealththroughtheLife-course; Copenhagen,DenmarkbPublicHealthUnit,ACESDouroI–MarãoeDouroNorte;EPIUnit–InstitutodeSaúdePública,UniversidadedoPorto;UniversityofTrás-os-MonteseAlto Douro;VilaReal,Portugal
cEuropeanCommission,Directorate-GeneralforEducationandCulture,SportsUnit;Brussels,Belgium dFriedrich-Alexander-UniversityErlangen-Nüremberg,InstituteofSportScienceandSport;Erlangen,Germany
eUniversityofZurich,Epidemiology,Biostatistics,andPreventionInstitute,PhysicalActivityandHealthUnit;Zurich,Switzerland
a
r
t
i
c
l
e
i
n
f
o
Articlehistory: Received22March2017
Receivedinrevisedform17January2018 Accepted24January2018 Keywords: Motoractivity Exercise Sports Health Policy Europe
a
b
s
t
r
a
c
t
Thisstudyaimstopresentinformationonthesurveillance,policydevelopments,andimplementationof
physicalactivitypoliciesinthe28EuropeanUnion(EU)countries.
DatawascollectedontheimplementationoftheEURecommendationonhealth-enhancingphysical
activity(HEPA)acrosssectors.InlinewiththemonitoringframeworkproposedintheRecommendation,
aquestionnairewasdesignedtocaptureinformationon23physicalactivityindicators.
Ofthe27EUcountriesthatrespondedtothesurvey,22haveimplementedactionsonmorethan10
indicators,fourcountrieshaveimplementedmorethan20indicators,andonecountryhasfullyaddressed
andimplementedallofthe23indicatorsofthemonitoringframework.
ThedatacollectedunderthisHEPAmonitoringframeworkprovided,forthefirsttime,anoverviewof
theimplementationofHEPA-relatedpoliciesandactionsatthenationallevelthroughouttheEU.Areas
thatneedmoreinvestmentarethe“SeniorCitizens”sectorfollowedbythe“WorkEnvironment”,andthe
“Environment,UrbanPlanning,andPublicSafety”sectors.Thisinformationalsoenabledcomparisonof
thestateofplayofHEPApolicyimplementationbetweenEUMemberStatesandfacilitatedtheexchange
ofgoodpractices.
©2018PublishedbyElsevierB.V.ThisisanopenaccessarticleundertheCCBY-NC-NDIGOlicense
(http://creativecommons.org/licenses/by-nc-nd/3.0/igo/).
1. Introduction
Physicalactivityisatthecoreofhealth and well-being.The benefitsofphysicalactivity–includingreducedriskof noncommu-nicablediseasesandlowerlevelsofstress,anxiety,anddepression –arewellknown[1].TheWorldHealthOrganization(WHO) rec-ommendsthatadults(includingelderly)engageinatleast150min ofmoderate-intensityaerobicphysicalactivityeachweek[2]. Fig-uresfromEuropeanUnion(EU)countriesindicatethatsixinevery 10peopleabove15yearsofageneverorseldomexerciseorplay anysports,andmorethanhalfneverorseldomengageinotherkind ofphysicalactivity,suchascyclingorwalking,householdchores
∗ Correspondingauthorat:WorldHealthOrganization,RegionalOfficeforEurope, DivisionofNoncommunicableDiseasesandPromotingHealththroughthe Life-courseUNCity,Marmorvej51,DK-2100Copenhagen,Denmark.
E-mailaddress:rodriguesdasilvabred@who.int(J.Breda).
orgardening[3].Anotherstudyconfirmsthistrendpointingout thatonethirdofadultsinEuropeareinsufficientlyactive[4],in particularthosefromlowsocioeconomicbackgrounds,minority ethnicgroups, andpeoplewithdisabilities[5]. Physicalactivity levels havedeclined among adolescentsof 11–15 years of age, withgirlsbeingconsistentlylessactivethanboys[6].Only34% of13–15yearoldsare activeenoughtomeetthecurrentWHO recommendationforchildrenandadolescents,whichisto main-tainatleast60minofmoderate-to-vigorousphysicalactivityevery day[2].Suchphysicalinactivitycontributesfurthertooverweight andobesity,especiallyinyoungpeoplefromlowsocioeconomic backgrounds[7].ResearchfromtheWHOEuropeanChildhood Obe-sitySurveillanceInitiativeshowsthatinsomeEuropeancountries morethan40%childrenareoverweightandapproximately25%are obese[8].Thispatternalsocontinuesintoadulthood,withcurrent dataindicatingthatmorethan50%ofadultsareoverweightinthe
https://doi.org/10.1016/j.healthpol.2018.01.015
majorityofEuropeancountries[9],thusfurthercontributingtothe proliferationofnoncommunicablediseases[5].
Toaddresstheproblemofphysical inactivity,many govern-mentsofthe28EUcountrieshavestartedtoactinthelast few years,byadoptingpoliciesthatpromotehealth-enhancing physi-calactivity(HEPA)[10].Nonetheless,ashighlevelsofinsufficient physicalactivityshownosignofdeclineinthepopulation,thereisa clearneedforgovernmentstodomore.EUMemberStates,meeting intheCounciloftheEU,acknowledgedthebenefitsofactionatEU level,leadingtotheadoptionoftheCounciloftheEU Recommenda-tiononpromotingHEPAacrosssectorsin2013[11].TheCouncil’s aimwastoencourageMemberStatestodevelopacross-sectoral approachinvolvingpolicyareassuchassport,health,education, environmentandtransportintheirnationalstrategiesandaction plans.InSeptember2015,ministersofthe53MemberStatesof theWHOEuropeanRegionadoptedthefirsteverPhysical Activ-ityStrategyfortheEuropeanRegion2016–2025[12].Thestrategy focusesonallformsofphysicalactivitypromotionthroughoutthe life-courseinordertoaddresstheburdenofnoncommunicable diseasesassociatedwithinsufficientactivitylevelsandsedentary behaviour,thusenablingallcitizenstolivehealthierandlonger lives.
IntheRecommendation,theCounciloftheEUrecognizedthat moredatawithreliableandtimelyinformation onthesituation acrossMemberStateswasinstrumentaltosupportnationaland regionalpolicy-making.Toaddressthisneed,theCouncilofthe EUproposedamonitoringframeworkbasedontheEUPhysical Activityguidelines[13],whichcontained23 indicatorscovering differentthemes relevantforHEPA(referredtohereafterasthe HEPAmonitoringframework).
Theaimofthispaperistopresentthefindingsfromthefirst roundofreportingontheHEPAmonitoringframework.This infor-mationrepresentsabasisforcomparisonofcountry-specificdata collectedonHEPApolicydevelopmentsacrosssectorsinEU Mem-berStates.
2. Materialsandmethods
TheCounciloftheEURecommendationcalledoneachEU Mem-berStatetoappointanationalHEPAfocalpoint,inaccordancewith nationallegislationandpractice.All28EUMemberStates desig-natedtheirfocalpointsbymid-2014andthenetworkofnational HEPAfocal points waslaunched in Rome in October 2014. Its mainrole,inlinewiththeRecommendation,wastocoordinatethe nationalcollectionofinformationforthemonitoringframework.
Asurvey tool wasdeveloped to explore nationalactions by MemberStatesanddescribetheircapacityinvarioussectors,asset outinthe23specificindicatorsoftheHEPAmonitoringframework. AnindicatorwasconsideredimplementedwhenaMemberState hadintroducedapolicyorprogrammeasdescribedbythis indi-cator,althoughinformationaboutthespecificpolicieswithineach indicatorwasalsoprovided.Thesurveyalsoincludedtheoption tomentionifanindicatorimplementationisbeingpreparedandis foreseeninthenexttwoyears.
Detailed information on definitions, operationalization, and datasourcesfortheindicatorscanbefoundintheEuropean Com-mission’sworkingdocument[14].
ThesurveywaspilotedbetweenOctober2014andJanuary2015, andbasedonaninitialsubsetofeightindicators.Arevised ques-tionnairewassentoutinApril2015andthecontactpersonsin eachcountrywereaskedtosubmitinformationonall23 indica-torstotheWHO RegionalOffice forEuropebytheend of June 2015.Uponreceipt,informationwascheckedforcompletenessand clarificationinordertoimprovethequalityofthedata.Toenable validation,thepolicydocumentscitedwerereviewedtoidentify
whethertheyhadbeenadoptedandendorsedbythegovernment andwhetherclearobjectivesandpolicyactionsweredescribed. Datawasassessedtoevaluatetheoverallsituationandtheextent oftheimplementationofHEPApromotionpolicies.
2.1. Monitoringframework
Themonitoringframework[14]iscomposedof23indicators relatingtothefollowingkeythemesoftheCounciloftheEU Rec-ommendation: international physical activityrecommendations andguidelines;cross-sectoralapproach;sport;health;education; environment,urbanplanning,andpublicsafety;working environ-ment,seniorcitizens,indicatorsevaluation;andpublicawareness (Table1).
2.2. Internationalphysicalactivityrecommendationsand guidelines–indicators1,2and3
Thesurvey askedwhetheror not officially adoptednational recommendationonphysicalactivitylevelsexists.Ifso,inwhich internationalrecommendation(s) [2,13,15–17] (if any) are they based,andwhichpopulationgroup(s)dotheytarget(i.e.children, adolescents,adults,orolderadults).
Itwasalsoaskediftherewasknowledgeofthephysical activ-itypopulationlevelsandtoreporttheprevalenceofadults,and childrenandadolescentsreachingtheminimumlevelsofphysical activityrecommendedbyWHO[2].
Countries reportedthe instruments,methodologies, sources, andsurveysthatsupportedthisdata.
2.3. Cross-sectoralapproach–indicators4and5
Theanalysisassessed theimplementationofa national spe-cificcoordinationmechanism(e.g.workinggroup,advisoryboard, coordinatinginstitution,etc.)forHEPApromotionandleadership ofsuchmechanisms.Italsoincludedtheassessment offunding allocatedspecificallytoHEPApromotion.
2.4. Sport–indicators6,7,8and9
InformationonHEPApoliciesadoptedonSportsectorwas col-lected.
Sportfor All refers thesystematic provision ofopportunities forphysicalactivityaccessibleforeverybody,ratherthanmainly favouringeliteathletes.CountrieswereaskedwhetheraSportfor Allpolicyand/oractionplanexists;ifso,whetheritisadedicated nationalSportforAllpolicythatdealsexclusivelywiththeissue,or ifitwasapartofabroadernationalpolicy.Thesurveyalsoexplored targetgroupsaddressedbythenationalHEPApolicy, implementa-tionofSportClubsforHealthprogrammes,andthearrangements madeforincreasingaccesstoexercisefacilitiesforsocially disad-vantagedgroups.
2.5. Health–indicators10,11and12
Informationontheexistenceofanationalhealthmonitoringand surveillancesystemwithpopulation-basedmeasuresofphysical activitywasalsocollected.Suchinformationisimportantfor track-ingtrendsandchangesinphysicalactivitylevelsovertime.Thisis criticalfordevelopingorimprovingnationalpoliciesonphysical activity.
Informationaboutpopulation-basedmeasuresofphysical activ-ityusedinthehealthsurveillancesystemswasasked.
The survey also assessed the existence of programmes or schemestopromotecounsellingonphysicalactivitybyhealth
pro-Table1
The23indicatorsoftheHEPAmonitoringframework.
Thematicareas Indicators
InternationalPArecommendationsand guidelines
Indicator1 Nationalrecommendationonphysicalactivityforhealth
Indicator2 AdultsreachingtheminimumWHOrecommendationonphysicalactivityforhealth
Indicator3 ChildrenandadolescentsreachingtheminimumWHOrecommendationonphysicalactivityforhealth Cross-sectoral
approach
Indicator4 NationalgovernmentcoordinationmechanismandleadershiponHEPApromotion Indicator5 FundingallocatedspecificallytoHEPApromotion
Sport Indicator6 NationalSportforAllpolicyoractionplan
Indicator7 SportClubsforHealthProgramme
Indicator8 Frameworktosupportofferstoincreaseaccesstoexercisefacilitiesforsociallydisadvantagedgroups Indicator9 TargetgroupsaddressedbythenationalHEPApolicy
Health Indicator10 Monitoringandsurveillanceofphysicalactivity
Indicator11 Counsellingonphysicalactivity
Indicator12 Trainingonphysicalactivityinthecurriculumofhealthprofessionals
Education Indicator13 Physicaleducationinprimaryandsecondaryschools
Indicator14 Schemesforschool-relatedphysicalactivitypromotion Indicator15 HEPAintrainingofphysicaleducationteachers Indicator16 Schemespromotingactivetraveltoschool Environment,urbanplanning,and
publicsafety
Indicator17 Levelofcyclingandwalking
Indicator18 Europeanguidelinesforimprovinginfrastructureforleisure-timephysicalactivity
Workingenvironment Indicator19 Schemestopromoteactivetraveltowork
Indicator20 Schemestopromotephysicalactivityattheworkplace
Seniorcitizens Indicator21 Schemesforcommunityinterventionstopromotephysicalactivityinolderadults Indicatorsevaluation Indicator22 NationalHEPApoliciesthatincludeaplanforevaluation
Publicawareness Indicator23 Nationalawarenessraisingcampaignonphysicalactivity
PA:physicalactivity;WHO:WorldHealthorganization;HEPA:health-enhancingphysicalactivity. fessionals,aswellasphysicalactivitytraininginthecurriculumof
healthprofessionals.
2.6. Education–indicators13,14,15and16
InformationonHEPApoliciesadoptedonEducationsectorwas collected.
Respondentswereaskedtoprovideinformationonthenumber ofhoursofmandatoryandoptionalphysicaleducationclassesin primaryandsecondaryschools.
Theexistenceofnationalschemesforactiveschoolbreaks(i.e. breaksbetweenschoollessons),foractivebreaksduringschool lessons,forafter-schoolHEPApromotionprogrammes,andto pro-moteactivetraveltoschoolwasassessed.
AquestionaboutwhetherornotHEPAwasincludedinthe cur-riculumofPhysicalEducationteachers,at thebachelor’sand/or master’sdegreelevel,wasalsoasked.
2.7. Environment,urbanplanningandpublicsafety–indicators 17and18
Severalquestionswereaskedaboutthevariousmodesof trans-portationfordailyactivities.Thisincludedmonitoringcyclingand walkingtimeand/ordistanceperdayforalltravelpurposes.The existenceofpoliciestopromoteactivetransportandtheuseofthe HealthEconomicAssessmentTool(HEAT)forWalkingandCycling [18]fromWHOwasalsoasked.
Furthermoretherewasalsoaquestionontheapplicationof theEuropeanGuidelinesforImprovingInfrastructuresfor Leisure-TimePhysicalActivityintheLocalArena[19]onplanning,building andmanaginginfrastructures.
2.8. Workingenvironment–indicators19and20
Thesurveyaskedwhetherthere existsanational schemeto promote activetravel to/from work,and incentiveschemes for companiestopromotephysicalactivityattheworkplace.
2.9. Seniorcitizens–indicator21
GiventhatmostEUMemberStates haveageingpopulations, andremainingphysicallyactiveisimportantforthehealthofolder people[20–22],countrieswereaskedforinformationonschemes forcommunityinterventionstopromotephysicalactivityinthis agegroup.
2.10. Indicatorsevaluation–indicator22
AquestionaboutifthenationalHEPApoliciesincludean eval-uationplanwasapartofthesurvey.
2.11. Publicawareness–indicator23
Thesurvey concludedbycollectinginformation onthe exis-tenceofnationalawarenessraisingcampaigns,includingwhether therewasaspecificfocusonissuessuchasmotivation,behavioural changeorculturalacceptability.
3. Results
InthisfirstroundofdatacollectionundertheHEPA monitor-ingframework,27ofthe28EUcountries(Greecedidnottakepart inthesurvey)answeredthesurveyontheimplementationofthe 23indicators.Thisdatapresenta goodoverviewofthestateof playofHEPApromotionintheEuropeanUnion(Table2).Detailed nationaldataandinformationcanbefoundinseparatecountry factsheetspublishedbytheWHO’sRegionalOfficeforEuropeand theEuropeanCommission[23].
Ofthe23 indicatorsof themonitoringframework, 22 coun-tries(81.5%) haveimplemented more than10 indicators,while fourcountries(14.8%)haveimplementedmorethan20indicators (Fig.1).Onlyonecountry(3.7%)fullyaddressedandimplemented all23indicatorsofthemonitoringframework(Table2).
Table2
ImplementationofHEPApoliciesinlinewiththe23indicatorsin27EUMemberStates.
I:implementedindicator;F:implementationforeseen;0:indicatornotimplementedorquestionnotanswered.HEPA:health-enhancingphysicalactivity;EU:European Union.CountrycodesareWorldHealthOrganizationofficial.
Fig.1.NumberofimplementedindicatorsacrossHealth-EnhancingPhysical Activ-itythematicareasbytheEuropeanUnionMemberStates.
MapSource:EuroGeographics.Note:Thedesignationsemployedandthe presenta-tionofmaterialonthismapdonotimplytheexpressionofanyopinionwhatsoever onthepartoftheEuropeanUnionconcerningthelegalstatusofanycountry, terri-tory,cityorareaorofitsauthorities,orconcerningthedelimitationofitsfrontiers orboundaries.
3.1. Nationalrecommendationsforphysicalactivityforhealth– indicator1
Nationalpolicyrecommendationsonphysicalactivityforhealth havebeenestablishedby19(70.4%)countries.Ofthese,18(66.7%) targetadults,17(63.0%)targetyoungpeopleand16(59.3%)target olderadults.
In10countries,thenationalrecommendationswerebasedon theWHO’srecommendationsalone[2],andonecountry’s recom-mendationsfollowedEU’sphysicalactivityguidelines[13].Eight countriesfollowedotherinternationalrecommendations,suchas thoseoftheUnitedStatesDepartmentofHealthandHuman Ser-vices[15],Canadianguidelines[17],theAmericanCollegeofSports MedicineandAmericanHeartAssociation[16],oracombinationof severalinternationalrecommendations.
3.2. Physicalactivitylevels–indicators2and3
Severalcountriesreporteddataonphysicalactivityprevalence frommorethanonesourceand/orinstrument(Table3).
Twelve countriesprovided physical activity prevalencedata for adults from their independent national studies. Data from internationalstudieswasalsoreported–sixcountriesreported Eurobarometer[3]dataandtwocountriesusedEuropeanHealth InterviewSurvey [24] resultsas theirnationaldataonphysical activityprevalence. In addition,one countryalsoreporteddata fromobjectivemeasurementsofphysicalactivityandused instru-ments such as accelerometers. In countries where no national studieswereavailable,physicalactivityprevalenceinadultswas
Table3
Varietyofsurveillanceinstrumentsusedtocollectprevalencedataonphysical activ-ityamongthecountriesoftheEuropeanUnion.
Instrumentused Numberofcountries
Adults
GlobalHealthObservatory 27
Nationalsurvey 12
Eurobarometer 6
EuropeanHealthInterviewSurvey 2
Nationalstudiesusingobjectivemeasurements 1 Childrenandadolescents
GlobalHealthObservatory 26
Nationalsurvey 8
Nationalstudiesusingobjectivemeasurements 2 HealthBehaviourinSchool-agedChildren 17 Note:Somecountrieshavereportedusingmorethanoneinstrument.
extractedfromtheWHO’sGlobalHealthObservatory(GHO) esti-mates, which was established to generate comparable data in multipleareas,includingphysicalactivity[25].
Numerousexisting standardizedinstruments,tosupportthe nationalmonitoringofphysicalactivitylevelsinadults,wereused. ExamplesincludetheInternationalPhysicalActivityQuestionnaire (IPAQ)[26];theGlobalPhysicalActivityQuestionnaire(GPAQ)[27]; theEuropeanCommission’sEurobarometer[3];oranational ver-ifiedsource(i.e.policydocuments,ornationalrecommendations, andnationalstudies).
Thereportedprevalencedatarevealedbigdifferenceswithin countries, depending onthe methodologies used. For example, onenationalsurveyreporteda34%prevalenceofphysicalactivity amongadults18–65yearsofage,butanothernationally represen-tativestudy,basedonobjectivemeasurementsofphysicalactivity, showed24%ofalladults(18–85yearsofage)meetingcurrentWHO recommendations. In another example, data from the national studyindicateda66%prevalenceofphysicalactivityamongadults (18–69yearsofage),whileEurobarometerdatasuggestthatonly 25%ofadultsinthatcountrymeetWHOrecommendedlevels.Such exampleshighlightdiscrepanciesindataduetoawidevarietyof instrumentsandmethodologiesused.Thiscreatesdifficultiesin establishingvalidityandcomparabilityacrosstheEU.
TheGHOestimatesforadultsweremuchhigherthan preva-lence levelsreported in national studiesor measured byother instruments.Forexample,inonecountrytheGHOestimatewas morethandouble thatshownfor thenational study(74%),and inanothertheGHOestimatewas80%comparedto18%reported bythenationalstudy.Overallforthe28EUMemberStates,GHO estimatesindicatedthatadultmenwereslightlymoreactivethan women,with59.7%–88%ofadultmalesand50.1%–82.1%ofadult femalesmeetingWHOrecommendedphysicalactivitylevels.As canbeseenfromtheexamplesabove,however,thesevaluescannot becomparedtothenationalstudies.
Therewerealsodifferencesininstrumentsandsurveyswithin countriesregardingthedataforchildrenandadolescents(Table3). AcrosstheEU,eightcountriesreporteddatafromtheirnational surveys,andtwo countriesextracteddatausingobjective mea-surementtechniques. In total, 17 countriesreported datafrom HealthBehaviourinSchool-agedChildren(HBSC)[28]survey.For example,thenationalsurveydata inonecountryreportedthat 20%of adolescents(11–15years old)reachedtheWHO recom-mendedphysical activity levels,but an objective measurement studyreportedthat 50%of 7–12yearsold inthecountrywere meetingtheWHOrecommendation.
GHOestimatesforadolescentswerederivedfromHBSCdata combinedfrom more than one roundof datacollection, possi-blyexplaining similar or slightly lower values when compared todata fromnational studies. For example, onenational study
Table4
Implementationofpoliciesbysectorandtargetgroupsaddressed.
HEPASector N.◦ofcountrieswithoneor
morepolicyimplemented
Sport 27
Health 23
Education 27
Environment,urbanplanning,andpublicsafety 17
Workingenvironment 16
Seniorcitizens 13
HEPA:health-enhancingphysicalactivity
reportedaphysicalactivityprevalenceof29%among11–15 year-olds,whereastheGHOvaluewas17%.Inanotherexample,national surveydata revealedaprevalenceof28% forchildren and ado-lescents(3–18 years),and GHOestimatesfor thesamecountry showedaprevalenceof17%foradolescents(11–15yearsold).Inthe EUMemberStatesforwhichGHOestimatesforadolescentswere available(nodatawasavailableforCyprus),9%–35.4%ofboysand 7.4%–20.4%ofgirls,weremeetingtheWHOrecommendedlevelof physicalactivity[25].
Onlyonecountryreportednodatafromchildrenand adoles-centsinthepresentstudy.
Whilealloftheinformationprovidedisvaluablebyofferingan overviewofsurveillanceindicatorsinthecountries,itisimportant tonotethatthesenationaldatadonotallowforcomparisonsacross countriesduetosamplingandothermethodologicaldifferences. 3.3. Cross-sectoralapproach–indicators4and5
Atotalof16countries(59.3%) reportedhavingafully devel-opedandimplementedspecificnationalcoordinatingmechanism (advisorybody,coordinatinginstitution,academia,workinggroup, orcommunity)onHEPApromotion.Onecountryreportedintense cross-ministrycooperationatthefederallevel,whichhadtheeffect ofacoordinatingmechanism,andfourmorecountriesenvisaged introducingamechanismwithintwoyears.
Twentyonecountries(63.0%)reportedhavingfundingallocated specificallytoHEPApromotionbetween2013and2015.
3.4. HEPApoliciesindifferentsectors
All27respondent countrieshavedevelopednationalpolicies oractionplansinoneormoreoftheHEPAsectorscoveredbythe questionnaire(Table4).
Itisnoteworthythatin2014and2015–followingadoption oftheCounciloftheEURecommendationin November2013– newpolicieswereadoptedinallthesectorsintheMemberStates. Morespecifically,newpoliciesinthesportsectorwereadoptedin 13,health-relatedpoliciesin10,education-basedpoliciesineight, environment-focusedpoliciesinthree,andpoliciesforsenior citi-zensinthreeMemberStates.
3.5. Nationalsportforallpolicyoractionplan–indicator6 Twenty-seven countriesreported implementing Sport for All policiesand/oractionplans.In22countries(81.5%)thesepolicies wereexclusivelydedicatedtotheissueatthenationallevel. 3.6. Sportclubsforhealthprogrammes–indicator7
SportClubsforHealthprogrammes,whichencouragesportclubs toinvestinhealth-relatedsportactivitiesand/orhealthpromotion withinsportactivities[14],wereimplementedinsevencountries (25.9%)withtwomorecountriesplanningtheimplementationof thesaidprogrammesin thenearfuture.Theprogrammes were
supported by national associations/organizations that provided assistanceinavarietyofareas,suchas:instructortraining,project developmentandpiloting,andsharingofbestpracticesand mate-rials.
3.7. Frameworktosupportofferstoincreaseaccesstoexercise facilitiesforsociallydisadvantagedgroups–indicator8
Tencountries(37.0%)reportedtheimplementationofspecific frameworkstosupportaccesstorecreationalorexercisefacilities forsociallydisadvantagedgroups.Ofthese,eighthadimplemented programmesnationwideandtwocoveredanumberof municipal-ities(15and23,respectively).Theprogrammesaimedtointegrate immigrantsorsociallyvulnerablegroupsbyprovidingaccessto recreationalfacilities,aswellastohelpdevelopsustainable facili-tiesandappropriateequipmenttomaximiseparticipationinsports andphysicalrecreation.TwoMemberStatesfocusedmoreonusing sportasanintegralcomponentofrehabilitationandreintegration programmesforpersonswithdisabilities[23].
3.8. TargetgroupsaddressedbythenationalHEPApolicy– indicator9
Therewasconsiderablevariationintheextenttowhich poli-ciesfocusedondifferentpopulationgroups(lowsocio-economic statusgroups;lowlevelsphysicalactivity;elderly;ethnic minori-ties;womenbeforeandduringpregnancy;etc.).Somecountries addressedtheneedsofmorethanonetargetgroupinanintegrated way,whileothersaddressedparticulartargetgroupsdepending ontheHEPAsector(sport;health;education;environment,urban planning,andpublicsafety;workingenvironment;andsenior citi-zens).All27countriesaddressedatleastonegroupwithparticular needofphysicalactivityinHEPApolicies.
3.9. Nationalhealthmonitoringandsurveillancesystem– indicator10
Establishedhealthsurveillanceand monitoringsystems,that include population-based measures of physical activity, were reported in 17 (63.0%) countries. Five countries (18.5%) envis-agedimplementationofthesesurveillanceandmonitoringsystems withinthenexttwoyears.
Fig.2illustrates which population-basedmeasuresaremost commonlyincludedinsurveillanceorhealthmonitoringsystems.
Agegroup,exerciseduration,frequencyofexercise,socioeconomic status, exerciseintensity, sedentarybehaviour, cycling/walking, andotherdomainsofphysicalactivityweremostfrequently mea-sured.
In some countries, additional aspects were measured. For example: annual check-ups for sport professionals, children and adolescents with increased physical activity (engaged in extra-curricularsportactivities);andphysicalfunctionalcapacity assessments,or measuresintended tocapturedifferent dimen-sionsofphysicalactivityinleisure-timeactivities.Inaddition,one countryreportedtheexistenceofaninterventiondatabasewithan insightintoquality,feasibilityandeffectivenessofvarious inter-ventionundertakings[23].
3.10. Counselingonphysicalactivity–indicator11
Thirteencountries(48.1%)hadprogrammesinplacetopromote physicalactivitycounsellingby healthprofessionals.These pro-grammesmostlyrelatedtothepreventionofnoncommunicable diseasesandprovidedguidancetohealthprofessionals,sometimes intheformoffreeonlinecourses.
3.11. Trainingonphysicalactivityinthecurriculumofhealth professionals–indicator12
Trainingonphysical activitywasincludedin curriculum for health professionals in 17 countries (63%), with 14 countries (51.9%)providingtrainingmodulesformedicaldoctorsand physio-therapists,andeight(29.6%)providingtrainingmodulesfornurses. Therewasconsiderablecountryvariationinthestructureand dura-tionofthemodules.
3.12. Physicaleducationinprimaryandsecondaryschools– indicator13
Whilealltherespondentscountrieshaveputintoactiona num-berofmandatoryphysicaleducationclasses,sixcountriesallowed foracombinationofmandatoryandoptionalphysicaleducation classesinprimaryschools,andfiveinsecondaryschools, respec-tively. Mandatoryphysical education hoursvaried from oneto almostfivehoursperweek,dependingonthegradelevelandon thecountryorregion.
Fig.2. Population-basedmeasuresofphysicalactivitycommonlyincludedinsurveillanceorhealthmonitoringsystems.PA:physicalactivity.Note:17countriesreported havingasurveillanceorhealthmonitoringsystemforphysicalactivityinplace.
3.13. Schemesforschool-relatedphysicalactivitypromotion– indicator14
Fifteen countries (55.60%) reported the implementation of atleast oneschool-related HEPApromotion programme:active breaks between school lessons (eight countries, 29.6%), active breaksduring schoollessons (four countries, 14.8%)and extra-curricular activities (11 countries, 40.7%). Across these pro-grammes, children were encouraged to participate in physical activities,withsomecountriesfocusingondisadvantagedchildren, oronchildrennot otherwiseinterestedin sports.Theydidthis byprovidingequipmentandinspirationtoparticipate,orhelping teacherstointegratemovementintoclasses.Fourcountries(14.8%) focusedmoreonextra-curricularsports.
3.14. HEPAintrainingofphysicaleducationteachers–indicator 15
HEPAwasincludedinthetrainingofphysicaleducationteachers in20countries(74.1%).Ofthose,15hadmandatorymodulesin place,whilenoinformationwasavailableforonecountrydueto federalsystemregulations.
3.15. Schemespromotingactivetraveltoschool–indicator16 To encourage active travel toschool, nine countries (33.3%) reportedimplementingprogrammes,mostlythroughmeasuresto makecyclingandwalkingtoschoolsafer.
3.16. Levelofcyclingandwalking–indicator17
Walkingandcyclingareamongthethreemainmodesof trans-portin20(74.1%)andeight(29.6%)countriesrespectively.
Lessthanhalfofthecountries(13,48.1%)reportedusingtheir nationalsurveytomonitortimeand/ordistancewalkedorcycled perdayforalltravelpurposes(school,work,orleisure).For exam-ple,inonecountry,walkingandcyclingaccountedfor18%and17% oftripstakenin2014,respectively.Fivecountrieshaveusedthe HEAT[18]toestimatethepotentialhealthandeconomicbenefits ofacycling and/orwalkinginfrastructurepolicy.Another coun-tryreportedusingatoolsimilartoHEAT[23].Forexample,itwas reportedthatinoneEuropeancapital,45%ofpeoplewhostudy orworkusebicyclesasthemainmodeoftransport,predictingan estimatedonemillionfewersickdaystill2020inthatcity[23]. Furthermore,somecountrieshaveintroducedcreativetax incen-tives, including VAT refundson bike purchases, tax exemption and/oremployeecompensationforwalkingorcyclingtowork,high parkingfees,and/orcongestioncharges.Sixteencountries(59.3%) showedatleastonepolicyinthisarea:presenceofeitheratravel survey,theuseoftheHEATtool,ortaxincentives.
3.17. Europeanguidelinesforimprovinginfrastructuresfor leisure-timephysicalactivity–indicator18
Fourcountries (14.8%) reportedimplementing the European GuidelinesforImprovingInfrastructuresforLeisure-TimePhysical ActivityintheLocalArena[19]andsixothercountrieshadplans todosointhenearfuture.
3.18. Schemestopromoteactivetraveltoworkandphysical activityattheworkplace–indicators19and20
Fourteencountries(51.8%)reportedimplementingactivetravel toworkschemes,whilephysicalactivityattheworkplacewas stim-ulatedbyschemesinplacein12countries(44.4%).
3.19. Seniorcitizens–indicator21
Schemes for community interventions to promote physical activityinseniorcitizenswerereportedin13countries(48.1%). Twocountriesreportedplanstoimplementitinthenearfuture. Programmesandstrategiestookvariousforms,including: provi-sionoforganisedHEPAprogrammesforolderadultsindifferent environments in cooperation withlocal communities (in eight countries);programmesfortheenhancementofbalanceand coor-dinationofolderadults,includingfrailtyandfallprevention(in three countries); education and exercise counselling (in three countries);andintegrationandavailabilityofphysicalactivity pro-grammesforall,especiallyforsociallydisadvantagedpeopleand olderadults(intwocountries).
3.20. HEPApoliciesevaluationplan–indicator22
Of152policiesoractionplansaddressingtheabove-mentioned HEPAsectors(sport;health;education;environment,urban plan-ning,andpublicsafety;workingenvironment;andseniorcitizens), 116(76.3%) containedan evaluationplan. Furtherinvestigation wasnotpossible,however,becausethequestiononlyaddressed whethersuchaplanexistsanddidnotcontainfurtherdetailson implementation.All27countriesreportedatleastoneevaluation planononeoftheHEPAsectors.
3.21. Nationalawarenesscampaignonphysicalactivity– indicator23
National strategies usually include an awareness-raising campaignonphysicalactivity.Successfulimplementationof com-municationcampaignstopromotepublicawarenessofphysical activitywasreportedby18countries(66.7%).Onecountryreported asmanyas14differentcampaigns,whileanotherimplemented nineseparatecampaigns[23].Theapproachofthecampaigns var-ied,andexamplesinclude:workshops;websitemonitoring;street cultureintegrationwithsports;andthedesignationofaspecific day,weekoryearofsports.Despiteusingdifferentstrategiesall ofthecampaignsaimedtoincreasethenumberofpeoplewhoare physicallyactiveandtoraiseawarenessofthebenefitsofphysical activity.Whilesomecampaignstargetedallcitizens,otherswere aimedatvulnerablegroups,suchaschildrenorseniorcitizens.The outreachofthecampaignswassometimesnationwide,whileat othertimesitwaslimitedtoaregionorspecificcities.
4. Discussion
Theresultspresentedinthisreportgiveagoodoverviewofthe stateofplayofHEPApolicyimplementationinEUMemberStates. ThisexercisewasabletoassesstheextenttowhichMemberStates haveimplementedpoliciesindifferentareas,tohighlightexamples ofgoodpracticesandtopinpointareasthatneedmore develop-mentor improvementin ordertoachievethethird Sustainable DevelopmentGoalestablishedbytheUnitedNations(goodhealth andwell-being)andtominimizetheprevalenceofoverweightand obesity[29].
Manychallengesremainwithregardtothecomparabilityofthe monitoringofHEPApoliciesandphysicalactivitylevelsacrossEU MemberStates.
First,definitionsofrecommendedlevelsofphysicalactivityvary betweencountries.Second,differentmethodsareusedtocollect data,whichvariagatestheresults.Forexample,nationalphysical activitysurveyssometimesusednon-standardizedinstrumentsor haveswitchedfromnon-standardizedtostandardizedinstruments (suchasIPAQorGPAQ)leadingtoalossoftime-seriesofnational data.
Inaddition, standardized instrumentswerenot alwaysused accordingtotheadoptedprotocols,leadingtoalackof comparabil-itybetweensurveyseventhoughthesameinstrumentshadbeen used.
Whilediscrepancies betweenGHOprevalenceestimates and resultsfromotherinstrumentswerefound,thisismostlikelydue tothemethodologyforcalculatingtheestimates.TheGHO esti-matesremainoneofthemostreliableandusedtoolsavailablefor inter-countrycomparisonatthispointintime.
Itisnotablethatonlyafewcountrieshaveimplemented poli-ciescoveringallareasofthemonitoringframework,indicatingthat thereisclearlyroomforimprovementacrosstheEU.
Areas with less indicators accomplishment that need more investmentarethe“SeniorCitizens”sectorfollowedbythe “Work-ing Environment”, and the “Environment, Urban Planning, and PublicSafety” sectors. Overall, indicatorswithless than 50% of accomplishment are indicators 7 (Sport Clubs for Health Pro-gramme),8 (Framework tosupportofferstoincrease accessto exercisefacilitiesforsociallydisadvantagedgroups),11 (Counsel-ingonphysicalactivity),16(Schemespromotingactivetravelto school),18(Europeanguidelinesforimprovinginfrastructuresfor leisure-timephysicalactivity),20(Schemestopromotephysical activityattheworkplace)and21(Schemesforcommunity inter-ventionstopromotephysicalactivityinolderadults).Morepolicies ontheseindicatorsshouldbeincentivized.
AsMemberStatesoftenprovidedreferencesintheirnational languages,thelanguagebarriermadeitchallengingtoverifysome oftheinformation.Whiletheeffectivenessofindividualpolicies couldnotbemeasured,theadoptionofpoliciescouldbeverified.
Somecountriesalsoprovided information onHEPAfunding. However,becausefinancialsupportforHEPAcomesfrom differ-entbudgetsatthenationallevel,comprehensivereportingonthis indicatorwasnotpossibleatthisstage.
Moreover,forsomeindicators thepossibility of“false nega-tive”replies(i.e.“no”actuallymeaning“noinformationavailable orsought”duetolackoftherelevantnetworkcontactsorresources rather than “no scheme/data existing”) should also be further explored.
Finally,datawascollectedatthenationallevel,butthe monitor-ingexercisedidnotexploreindetailanyachievementsatregional andlocallevels.
Forfutureroundsofdatacollection,itwillbeessentialtomodify thesurveyinstruments,e.g.byusinganonlinetool,andto spec-ifyindicatordefinitionsinmoredetail toreducethemarginfor interpretation,andthereby,marginoferrorwhenrecordingthe data.ThiswouldenablemorestreamlineddatacollectionacrossEU countries,thusfacilitatingbetterinter-countrydatacomparisons, whicharemuchneeded.
Furthermore,toincreasethecomparabilityofprevalencedata overtime,itwouldbebeneficialtousethesameinstrumentsover time.Ascountriesimprovetheirnationalsurveillancesystemswith moredata,internationalcomparisonswillalsoimprove.
Futuredatacollection exercises under theHEPAmonitoring frameworkcouldalsoconsiderexploringwaystobettercapture effortsattheregionalandpossiblyeventhelocallevel.
TheCounciloftheEURecommendationandtheWHOPhysical activitystrategyfortheWHOEuropeanRegion2016–2025appear tohaveprovidedastrongincentiveforMemberStatestoact.This firstroundofresultsfromthemonitoringframeworkshowsthe needtocreate HEPAcoordinationstructures overthe nextfew years.Thedatapresentedhereshouldalsobeusedasabasisfor MemberStatesto sharetheirexperiences, suchas throughthe HEPAfocalpointnetwork.Thisstudyhighlightsvaluableexamples ofnationalsuccessesandgoodpractices,providinginspirationfor
thosecountriesthatareintheprocessofdevelopingormodifying theirnationalstrategiesandpolicies.
5. Conclusion
ThedatacollectedunderthisHEPAmonitoringframework pro-vided,for thefirsttime, an overviewof theimplementationof HEPA-relatedpoliciesandactionsatthenationallevelthroughout theEU.Areasthatneedmoreinvestmentarethe“SeniorCitizens” sectorfollowedbythe“WorkingEnvironment”,andthe “Environ-ment,UrbanPlanning,andPublicSafety”sectors.Thisinformation alsoenabledcomparisonofthestateofplayofHEPApolicy imple-mentationbetweenEUMemberStatesandfacilitatedtheexchange ofgoodpractices.
Conflictofinterest
Nonedeclared.
Disclaimer
JBandGGareWHOstaffmembers.Viewsexpressedhereare theirown.
Acknowledgements
This study was funded by the European Commission Directorate-General for Education and Culture. We thank the members of the EuropeanUnion Physical Activity Focal Points Network,setupinthecontextoftheCounciloftheEuropeanUnion Recommendation on Health-Enhancing Physical Activity across sectors, for theirvaluable input, support,and final approval of theinformation.Ayearlyreportabouthealth-enhancingphysical activitybytheEuropeanCommission,basedontheWorldHealth Organization’sresearch,hasalreadybeenpublished.Moreover,we wouldliketothankEvaMartin-Diener(UniversityofZurich),and KyleFergusonandMarieMurphy(UniversityofUlster)fortheir workonthecountryquestionnaires.
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