Fourth meeting of the European Union Physical Activity Focal Points Network

Limassol, Cyprus December 2016 11 April 2016 Original: English

Fourth meeting of the European Union Physical Activity

Focal Points Network

Meeting Report

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ABSTRACT

The WHO Regional Office for Europe and the European Commission have been cooperating to develop and scale-up monitoring and surveillance of health-enhancing physical activity in the European Union Member States. An important element of this collaboration is the network of national physical activity focal points. These focal points help to provide and validate information on physical activity from EU Member States in line with the monitoring framework established by the Council Recommendation of 2013 and to integrate these data into WHO Europe’s information system for nutrition, obesity and physical activity, NOPA. The work of the focal point network meetings in 2014 and 2015 has led to the publication of Factsheets on health-enhancing physical activity in the 28 European Union Member States of the WHO European Region. The fourth meeting of the focal point network, hosted by the Cyprus Organisation for Sports in Limassol on 11 April 2016, discussed the factsheet publication and the next steps to be taken to promote and update collected information around the HEPA indicators. The main aim was to prepare the ground for the next iteration of information collection.

© World Health Organization 2016 All rights reserved. This information material is intended for a limited audience only. It may not be reviewed, abstracted, quoted, reproduced, transmitted, distributed, translated or adapted, in part or in whole, in any form or by any means.

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CONTENTS

Background .................................................................................................................... 4 Welcome addresses ........................................................................................................ 5 Physical Activity Strategy for the WHO European Region 2016-2025 ........................ 5 Main findings from the study on the implementation of the European Physical Activity Guidelines and discussion on the recommendations ....................................... 7

Procedures and technical aspects ............................................................................... 8 Issues on specific indicators..................................................................................... 10 Factsheets and other outputs .................................................................................... 14 Future networking .................................................................................................... 16

Recent developments in promoting physical activity for health in the United Kingdom...................................................................................................................................... 17 Presentation of the ERASMUS+ Safeyou project, ‘Stay fit, Stay clean’ .................... 18 Presentation of the WHO European database on nutrition, obesity and physical activity (NOPA) database ............................................................................................ 19 Conclusions and next steps .......................................................................................... 19 ANNEX I: LIST OF PARTICIPANTS ....................................................................... 21

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Background In the context of the European Union Council Recommendation on Promoting Health-Enhancing Physical Activity (HEPA) Across Sectors adopted in 2013, EU Member States have been requested to appoint national physical activity focal points notably to support the framework to monitor HEPA policies and physical activity. As part of the collaboration to implement the above mentioned Recommendation in the EU and to promote physical activity across Europe, the European Commission, Directorate-General for Education and Culture (DG EAC), Sport Unit, and the WHO Regional Office for Europe, Division of Noncommunicable Diseases and Promoting Health through the Life-course, held the fourth meeting of this focal points network on 11 April 2016 in Cyprus. Despite increasing knowledge about the importance of health-enhancing physical activity for the individual, for health systems and for economies, the proportion of citizens who reach recommended physical activity levels has not increased overall. Rather, evidence shows that rates of physical inactivity in the EU remain extremely high. The EU Physical Activity Guidelines, the EU Council Recommendation on Promoting Health- Enhancing Physical Activity Across Sectors, as well as the WHO Physical Activity Recommendations and the Physical Activity Strategy for the WHO European Region 2016-2025 provide policy recommendations that can contribute to reversing this trend. Some of these principles have been implemented with relative success in several Member States. However, challenges continue to exist, and there is a need to improve the design and implementation of policies that promote physical activity across sectors. In particular, more information and data is needed about policy developments and the epidemiological situation in the field of physical activity in Europe. Following the 2013 Council Recommendation on HEPA, the European Commission and the WHO Regional Office for Europe have been cooperating to develop and scale-up monitoring and surveillance of health-enhancing physical activity in the European Union Member States. An important element in this context is the work of the network of national physical activity focal points to help provide and validate information on physical activity from EU Member States in line with the monitoring framework established by the Recommendation and to integrate them into WHO Europe’s information system for nutrition, obesity and physical activity, NOPA. The three focal point network meetings held in 2014 and 2015 have led to the publication of the Factsheets on health-enhancing physical activity in the 28 European Union Member States of the WHO European Region.1 The fourth meeting, hosted by the Cyprus Organisation for Sports in Limassol on 11 April 2016, discussed the factsheet publication and the next steps to be taken to

1 Available in English at: http://www.euro.who.int/en/health-topics/disease-prevention/physical-activity/country-work/factsheets-on-health-enhancing-physical-activity-in-the-28-eu-member-states-of-the-who-european-region

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promote and update collected information around the HEPA indicators. The main aim was to prepare the ground for the next iteration of information collection. Participants included the focal points, representing 23 Member States, the European Commission, represented by staff from DG EAC/Sport Unit, and the World Health Organization, represented by staff from the WHO Regional Office for Europe. Some external experts (invited as observers), three temporary advisers and a rapporteur were also present.2

Welcome addresses On behalf of WHO and the Regional Director, João Breda welcomed all participants and expressed WHO’s gratitude to the host organisation, Cyprus Sport Organisation, and the colleagues who have prepared the meeting. The focal point network can be proud of the concrete achievements realised in the last two years and this meeting marks the start of the second phase of its work. Yves Le Lostecque welcomed participants on behalf of the European Commission. He added his thanks to the hosts and organisers and also thanked WHO for the meeting preparation and the excellent cooperation. This meeting is very timely because there are a number of important discussions taking place within the EU in relation to the future of HEPA in EU sport policy. João Breda presented the draft agenda and the agenda was adopted.

Physical Activity Strategy for the WHO European Region 2016-2025 João Breda presented the context and background to the Physical Activity Strategy for the WHO European Region 2016-2025. Low physical activity is an important contributor to the global burden of death and disability. Globally, low physical activity accounted for more than 2 million deaths and more than 45 million years lost to death or disability (DALYs) in 2013.3 In addition, physical inactivity is connected to many other causes (obesity, hypertension, etc.) It is particularly worrying that obesity projections in a forecasting exercise by the WHO Regional Office for Europe with the UK Health Forum 4 —and recently reinforced by a new analysis by the NCD Risk Factor Collaboration5—suggest that very few, if any, European countries are on track to meet the global target to halt the increase in obesity by 2025.

2 See Annex 1 for a full list of participants. 3 GBD 2013 Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. http://dx.doi.org/10.1016/ S0140-6736(15)00128-2 4 http://nhfshare.heartforum.org.uk/RMAssets/NHFMediaReleases/2015/ECO2015WEDSPRESSWHO4.pdf 5

NCD Risk Factor Collaboration. (2016) Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19·2 million participants. The Lancet , Volume 387 , Issue 10026 , 1377 – 1396.

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The situation in children and adolescents is of particular concern. Data from WHO’s Childhood Obesity Surveillance Initiative (COSI) found prevalence of overweight (including obesity) was higher than 20% in all countries participating in the most recent round of surveillance, and that prevalence of severe obesity in children is increasing, reaching 6% in some countries. The data also show that childhood obesity disproportionately affects the most vulnerable. New data from the Health Behaviour in School-aged Children study found a worrying picture on self-reported overweight and obesity—with highest prevalence levels in Southern Europe and the sharpest increase witnessed in Eastern Europe. It also found that levels of physical activity remain very low, with only 25% of 11-year olds and 16% of 15-year olds meeting current physical activity guidelines.6 It is clearly important, therefore, to acknowledge the challenges of physical inactivity and sedentary behaviour in adolescents. Analysis of the implementation of policy actions to promote HEPA in the EU highlights that there are still many opportunities to take action. In particular, there is room for improvement on surveillance, ensuring more than two hours of physical education per week in schools, implementing schemes for promoting travel to work and physical activity in the workplace, and including physical activity in the training curricula of health professionals. While there have been many national awareness campaigns implemented, more action is needed to bring about behavioural change. There is also a particular need for physical activity policies targeting particular vulnerable groups, such as those with low socio-economic status, older people etc. It is against this backdrop that Member States issued a very strong mandate to WHO in 2013 to develop a new regional strategy specifically focused on physical activity. The Physical Activity Strategy for the WHO European Region 2016-2025 was adopted at the Regional Committee meeting in Vilnius in September 2015. The mission of the strategy is to inspire governments and stakeholders to work towards increasing the level of physical activity among all citizens of the European Region by:

• promoting physical activity and reducing sedentary behaviours; • ensuring an enabling environment that supports physical activity through

engaging and safe built environments, accessible public spaces and infrastructure;

• providing equal opportunities for physical activity regardless of gender, age, income, education, ethnicity or disability; and

• removing barriers to and facilitating physical activity.

Steered by six guiding principles, the Strategy focuses on five priority areas:

1. Providing leadership and coordination for the promotion of physical activity. 2. Supporting the development of children and adolescents. 3. Promoting physical activity for all adults as part of daily life, including during

transport, leisure time, at the workplace and through the health-care system. 4. Promoting physical activity among older people. 5. Supporting action through monitoring, surveillance, the provision of tools,

enabling platforms, evaluation and research.

6 HBSC/WHO. Growing up unequal: gender and socio-economic differences in young people’s health and well-being. Health Behaviour in School-aged Children (HSBC) study: main findings from the 2013/2014 survey.

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This powerful strategy is available on the website and it is intended to be widely disseminated, including outside the health sector. The strategy, combined with the EU Guidelines and Council Recommendation, should provide the political instruments that policymakers need to take action to promote physical activity. Discussion Since the strategy was adopted in September it is now time to push on with implementation. There was a request for clarification on the concrete steps needed to put this into practice. This is an area where discussion with the focal points should be helpful—to help identify how the network can help with implementation. France has introduced a new measure in a recently adopted French health law. This provision enables the remuneration of health professionals for prescription of physical activity. Efforts are underway to provide the doctors with all the training and tools that they need. The UK indicated that this had been attempted in a two-year pilot project to remunerate general practitioners for exercise prescriptions, but the scheme had suffered from a lack of support from doctors.

Main findings from the study on the implementation of the European Physical Activity Guidelines and discussion on the recommendations Alfred Rütten and Peter Gelius, both from the Institute of Sport Science and Sport, Friedrich-Alexander University Erlangen-Nuremberg, Germany, and Sonja Kahlmeier, University of Zurich, Switzerland, presented an overview of the work of the consortium that won the tender to provide support and training for Member State focal points in data collection (hereafter referred to as ‘the Tender group’). More specifically, they outlined the findings of their final progress report and presented specific recommendations for discussion. The proposed recommendations were discussed with participants during the course of the presentation, and a summary of the discussion is incorporated into this section. The activities of the Tender group comprised:

• Providing support to WHO for finalizing the questionnaire on the 23 indicators of the monitoring framework, including making specific recommendations for question design for certain indicators.

• Organizing a series of three webinars and on-going support via phone and e-mail to support focal points filling out the questionnaire.

• Conducting in-depth reviews of the Commission’s Staff Working Document (SWD), the completed questionnaires and focal points’ responses, and the completed physical activity country factsheets (the ‘document review’).

• Carrying out a specific situation analysis of six countries (selected to ensure a good geographical spread, to include small, medium and large countries, and to reflect different political systems) to get feedback and to learn more about how Member States completed the questionnaire.

• Providing conclusions and recommendations to the European Commission regarding the further development of the SWD.

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The findings of the document review and situation analysis had both confirmed the complexity involved in implementing the monitoring framework, reflecting, in fact, the complex nature of the EU Guidelines. The document review found that 147 of the 23 indicators were assessed as being well applied, understood and answered, with only minor amendments necessary. For a further group of six indicators8 some more substantial amendments seem to be needed. Finally, there are three indicators9 where more extensive discussion appears to be warranted. The situation analysis comprised desk research and analysis, two-day country visits to carry out semi-structured interviews with focal points and extended focus group discussions, and a specific workshop meeting, in December 2015, on measuring prevalence of physical activity. The key conclusions from the situation analysis are:

• Overall response from the country Focal Points on the questionnaire was good. They were able to provide a wide range of the answers in a very tight time frame.

• Member States appreciated the support provided by the EU, WHO, and

the Tender group (including the proposed update of the SWD, the webinar system, and the opportunity to provide detailed feedback during the country visits).

• Overall feedback from focal points on the country factsheets was positive.

• Focal points provided detailed feedback on questionnaire procedure and

technical details, on several specific topics, on the factsheets and other potential outputs, and on issues related to national and EU-level networking.

As a result, the Tender group was able to draw up a series of conclusions and recommendations which were presented to the group for discussion.

Procedures and technical aspects The document review identified a number of technical issues with the questionnaire, such as, for example, the possibility that both ‘yes’ and ‘no’ boxes could be ticked for a question. Some sub-items had been added to the questionnaire but these appear to detract from the focus on the 23 indicators of the monitoring framework. Other issues identified included: failure to repeat definitions at appropriate points in the questionnaire; inclusion of web links to key documents that were not sufficiently detailed; and, inadequate explanation of required conditions to be able to answer ‘yes’. The situation analysis highlighted the diverse strategies adopted by the focal points to 7 Indicators 1,4,7,8,10,11,14,15,16,18,19,20,21 and 23. 8 Indicators 3,6,9,12,13 and 22. 9 Indicators 2,5 and 17.

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fill the questionnaire—some focal points completed the questionnaire themselves, while others delegated portions of the questionnaire or organized network meetings. This analysis also highlighted the existence of conflicting views about the level of detail included in the questionnaire—while some consider it is too detailed others think that it does not provide enough room to explain complex national situations. Some problems with language used to frame the questions and definitions of key terms in the questionnaire were also identified. Following this analysis, the Tender group presented the following recommendations for discussion:

• Ensure the questionnaire is compatible with different approaches to data collection in Member States.

• Discuss optimal length and level of detail of questionnaire. • Specify definitions for central terms (e.g. “HEPA-related policies”,

“guidelines”, “sports clubs”). • Specify criteria for when to tick a box/report a policy. • Consider pre-filling questionnaires with available information before sending

them to focal points. Discussion There was support for the idea of pre-filling the questionnaire wherever possible. WHO has used this approach in other areas and found it to be useful. Another advantage is that NGOs or other bodies, such as scientific or professional associations, could be asked to gather the initial data. The pre-filled data would always be reviewed and validated by the focal points. The second round questionnaire will, of course, be pre-filled with much of the data from the completed first round of data collection. In relation to the length of the questionnaire, there was recognition that the questionnaire is very long, but that this appears to be necessary. It is clear that the focal points need to reach out to other sectors in order to find out about what is being done in other areas (e.g., active travel, urban planning). This reflects the nature of the EU Guidelines and creation of such cross-sectoral links can be seen as one of the positive side-effects of the monitoring framework itself. It was pointed out, however, that there are some areas of overlap in the questionnaire and that it can be difficult for focal points to know who to send each segment to, sometimes resulting in more than one answer being provided and thereby creating a dilemma for the focal point. It would be helpful for focal points to have more guidance on which segment of the questionnaire should be sent to which sector. There was positive feedback on the webinars, which had proved extremely useful. It was noted, however, that the organization of these webinars had been rushed and suggested that, in future, it would be useful to run repeat sessions and try to ensure 100% participation in the webinars. A second round of webinars on the same indicators—in order to give feedback on the initial answers provided—would also be useful. There was discussion about the question of when—at which point in their

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development—initiatives should qualify for inclusion in the reporting. This appears to have been interpreted differently by countries, generating a very diverse picture and giving rise to concern about the comparability of information between countries.

Issues on specific indicators The document review and situation analysis together highlighted a number of issues about specific indicators.

Prevalence rates (Indicator 2 Adults reaching minimum physical activity recommendations and Indicator 3 Young people reaching minimum physical activity recommendations) A number of issues were identified with these prevalence indicators. There was recognition of the wide variability of methodologies and instruments used to collect national prevalence data. There were concerns about differences between international (Global Health Observatory) and national data—the use of two different sets of data created confusion and could create particular problems for advocacy and media communication. In relation to the Eurobarometer, repeated changes to the methodology were recognised to limit comparability of data over time. Other issues identified included the reporting of unpublished data. The focal points were appreciative of the workshop on instruments to measure physical activity prevalence rates held in Erlangen in December 2015. Potentially, there are similar problems with comparability of data from Indicator 13 on the number of hours of physical education in schools, because definitions of physical education vary and comparisons between countries are difficult. The Tender Group made a number of recommendations for discussion: • Agreement on reporting of unpublished data (verification). • Discuss ways to obtain better data and foster exchange between Member States,

the EU, and WHO (e.g., via the proposed study on calibration/ conversion of questionnaires).

• Discuss ways to obtain higher quality and more realistic data on physical activity prevalence rates.

Discussion There was broad agreement on the importance of the issues raised and the need to tackle the differences in prevalence measurement methodologies and issues of comparability. A number of suggestions were made in discussion, including:

• incorporation of data collection into future European Week of Sport campaigns, whereby all Member States would be collecting data at the same time;

• taking forward the use of objective measurement methodology, already being used by, for example, Finland and Denmark;

• including measurement of physical capacity (especially in children).

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This first round of data collection was, inevitably, a starting point in terms of prevalence estimation and comparability. Much progress has been made since the late 1990s, when there was absolutely no comparability of physical activity data, and work is ongoing to improve national estimates, with more validation and calibration. Better national estimates will, in turn, feed in to improved WHO estimates—which remain important for generating data that are comparable between countries. An idea that emerged from the 3rd Focal Point meeting in 2015 is now being taken forward—namely, a study on the different measurement instruments in use (IPAQ, GPAQ, EHIS, national instruments and objective measurement techniques). This study should enable calibration of results against the various instruments and should clarify how these instruments relate to objective measurement techniques. This last element is important because objective measurement techniques are expensive and cannot realistically be applied at the population level, but calibration of questionnaire methodologies with the results of objective measurements on small samples would be useful. There was clarification that the study is absolutely not intended to produce a new instrument, rather it is to enable better use of existing instruments. This study has been under discussion for some months and is likely to go ahead, as part of the forthcoming future collaboration between WHO and the European Commission. There was support for the idea, in principle, of a pan-European surveillance network to generate comparable and sustainable data across the EU as a long-term vision. WHO has established a Childhood Obesity Surveillance Initiative, which now has 36 countries involved and is successful in generating reliable and comparable data on childhood overweight and obesity. Nonetheless, it is important to recognise that such networks require funding and resources. There was some discussion about the current WHO recommendations on physical activity. Although there are no immediate plans to revise the recommendations, these may need to be updated in coming years. It is important to bear in mind, therefore, that, while it is useful to express data on the percentage of the population meeting the WHO recommendations, further detail is also required to enable long-term trends to be plotted if the recommendations do change.

Levels and sectors (Indicators 13 Physical education in schools, 6 National Sport for All policy or action plan, 9 Target groups and 22 National policies with a plan for evaluation) For a number of indicators, including those listed above, the questions were difficult to answer because of uncertainty of which levels of information—for example, national, sub-national, federal or regional—are relevant for reporting. This is clearly a real issue for countries that have federalized/devolved/decentralized governments. There was also the issue of whether pertinent activities carried out at regional or local levels warrant inclusion. There were conflicting views—while some consider that reporting on local level information is absolutely essential to be able to portray a meaningful picture, others think that to include the plethora of sub-national information is unrealistic. For some, particularly in federalized systems, this represents an enormous task.

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A similar issue is that difficulty in capturing information on policies that are cross-sectoral further complicates data collection. There were two recommendations for discussion:

• Discuss rules regarding which sub-national policies and programmes should be included.

• Discuss ways to improve reporting of sub-national policies and programmes. For example, this could mean inclusion of an instruction to ‘include information on subnational policy-documents where relevant (e.g. for strongly federalized or decentralized countries).’ This is the approach adopted in the HEPA Policy Audit Tool.

Discussion There was support for inclusion of some general information that activities are taking place at the sub-national level, without any requirement for details. It was suggested that national-level umbrella organisations, grouping together sub-national- or local-level bodies, could be useful partners for information gathering. In general, exploration of networks—such as, for example, the Healthy Cities networks—is recommended to facilitate the focal points’ work. There was also some discussion of the potential for collaboration with the HEPA Expert Group’s work in collecting information on policies/strategies where there may be areas of overlap. The Expert Group does not have an overview of what is happening at the regional/sub-national level, but it is collecting information on policies and strategies that do not have any funding attached and this would be a useful area for information exchange with the focal point network.

Funding (Indicator 5) Although most countries did provide information, there were some issues with this indicator. When information was not provided it was difficult to distinguish whether no funding had been provided or no information was available. There was also a need to be clearer that funds related to competitive sports should be excluded. More information was also needed on how to report qualitative information if no figures are available to report. Difficulties were also noted in reporting funding in situations where the programmes are not entirely funded by one sector or by national governments or where HEPA funds are difficult to isolate from other elements of a budget, especially outside the sport and health sectors. Focal points are, in effect, forced to choose between over-reporting or under-reporting. The following recommendations for discussion were proposed:

• Discuss how to specify rules for how to report funding, especially in cases of cross-sectoral and cross-level funding.

• Discuss alternative options: o Provision of information on funding for individual policies that might

be related to HEPA (report in a list); o generic question on the existence of any dedicated lines of funding

attached to HEPA (and additional information, if so).

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Discussion There was widespread agreement that this is a challenging indicator. Concern was expressed about the extreme difficulty of obtaining comparable data on funding because there are so many cross-sectoral or cross-level activities. As a direct consequence of the cross-sectoral nature of HEPA activities, it is extremely difficult for any country to say exactly what it spends on HEPA. It was suggested that it is preferable to focus on the effects of HEPA spending rather than the level of funding. Nonetheless, funding is a feature of the EU Guidelines, it is a strong indicator of the level of national importance attached to HEPA, and the indicator is included in the monitoring framework so continued reporting on it will be required. Suggestions of possible ways to deal with this in future include:

• Reporting on the funding for health promotion and how much of it goes into HEPA.

• Include information on funding attached to particular policies (particularly those that feature on the factsheet) but do not report an overall national figure.

• Systematically request information on funding for all the actions that reported in the questionnaire.

It was agreed to work on developing a softer approach to collecting data on this indicator. This may not enable cross-country comparisons, at least initially, but would enable intra-country comparisons over time to highlight progress (or the lack of progress).

Urban planning (Indicator 18 Guidelines for leisure-time physical activity (LTPA) infrastructure) It appears that implementation of these guidelines for LTPA was under-reported. Another issue with this indicator is how countries who have not implemented the EU LTPA guidelines (referred to as the IMPALA guidelines), as such, but who do have similar or equivalent guidelines should report. The following recommendations for discussion emerged:

• Discuss potential need to strengthen aspect of urban planning (as an important prerequisite for adopting a healthier lifestyle) in the monitoring framework.

• Consider options for reporting national guidelines similar or equivalent to those proposed at the EU level.

• Discuss including an additional dedicated question on urban design. Discussion There was agreement that there needs to be a better way to reflect activities that correspond to elements of the IMPALA guidelines, even if they do not include all aspects of the guidelines or an explicit statement on implementation of the IMPALA guidelines. There was some support for the inclusion of a question on urban planning, but it was also recognised that this is often an issue for local municipalities so data collection may be difficult. Exploration of more creative ways to access and reflect this

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information is warranted, including, for example, reporting on the incorporation of these aspects in architectural schools’ curricula or use of the Healthy Cities network to collect information.

Workplace physical activity promotion (Indicator 19 Schemes to promote active travel to work, Indicator 20 Schemes to promote physical activity at the workplace) A sizeable proportion of countries (14 for indicator 19 and 16 for indicator 20) reported that no activities existed. It would be useful to explore how data were collected to ensure that this does not represent under-reporting. Focal points reported that these indicators were difficult to report because they happen mostly at the local level, are usually cross-sectoral, and are implemented by private companies who do not report back to governments. This is a very relevant indicator, so it is important that there is full reporting on it. The Tender Group recommended discussing how data could be collected to ensure that no activities in worksite physical activity promotion are missed. Discussion Several participants confirmed that data on this indicator is difficult to collect. It was suggested that reaching out to the HEPA Europe working group on workplace HEPA promotion would be useful. This group could potentially provide some information that could be pre-filled in the next round of the questionnaire, for validation by focal points. It would also be helpful to define the scope and terminology more precisely. Once again, the creative use of networks (such as chambers of commerce, trade unions or employers’ bodies) was recommended.

Factsheets and other outputs The situation analysis reported generally positive feedback on the country factsheets. There were some suggestions for improvements in relation to the cover photographs, the level of detail in some sections, the inclusion of Yes/No tables and the reference lists. In commenting on the process, focal points reported uncertainty about what information would be included. There remains some lack of clarity about the exact purpose of, and target audience for, the factsheets. Overall, there was positive feedback from focal points on the Staff Working Document. Not all respondents, however, had had time to consult the document when completing the questionnaire. There were a number of recommendations for discussion: Country factsheets:

• Further specify the purpose and target group of the factsheets (and of the entire monitoring framework).

• Discuss which information/indicators to include in future factsheets. • Discuss frequency of revision (Suggestion DG EAC: every three years).

Staff Working Document:

• Final updated version of the SWD should be foreseen.

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• Focus could be put on indicators where less information was available. Other outputs:

• Consider additional products (topical factsheets, info graphs etc.). Discussion The question was raised about what is going to be done with all the additional information provided in the questionnaire, i.e. the information not included in the factsheets. Some of this information will be included in the revamped WHO Nutrition, Obesity and Physical Activity (NOPA) database and some information will feature in scientific publications. Such publications may include a dashboard of results on all indicators from all countries. In relation to the content and style of the factsheets there were a number of comments and suggestions:

• There was discussion of the target audience for the factsheets. In fact, while the factsheets are intended to be useful for national policymakers it is also important to remember that the most frequent users of WHO publications are researchers and the media. This means that it is important to find a balance between in-depth information for those interested in the detail and simple, clear messages for others.

• Greater emphasis on areas where improvements are needed would be useful. • More breakdown of prevalence figures by sub-group (age and gender) would

be helpful, particularly for policy development and advocacy. • Inclusion of an organisational chart of Ministries, institutions and other

organizations involved in physical activity could be of interest, along with an indication of whether the system of government is centralized, federal, etc.

• Inclusion of a table showing prevalence of overweight and obesity should be considered.

Differing views were expressed about the desired frequency of the data collection process. The suggestion from the European Commission and WHO was that data collection should be repeated at least every three years. There was some support for this proposal. Some concerns were expressed, however, that, because of the effort involved in completing the questionnaire, every four or five years might be more appropriate. Participants were reminded that the process should be a great deal simpler next time round, since a lot of the information will have been completed this time and should be easy to update. It is not expected that there will be new developments to report for all indicators every time. There were also serious concerns about leaving too long a gap between data collection rounds—especially since monitoring and analysis of trends is considered very important, and the focal point network exists to collect data and track progress over time. The data collection should also be seen in the context of the new WHO Physical Activity Strategy for the European Region, which covers the period 2016-2025. Given the expectation that data collection will be much easier second-time round, it was proposed that the second round of data collection be repeated in three years and that if focal points find that the process is still very cumbersome, less frequent data collection can be discussed again at that stage. It is also important to remember that the questionnaire is a tool for organising knowledge and information, and that the process of data collection, in itself, promotes much-needed intersectoral collaboration.

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There was some discussion of developing an intermediate solution, whereby some key indicators—such as prevalence—could be reported more frequently. There was support, in principle, for a proposal to synchronise the data collection with other key data collection exercises (e.g., EHIS, HBSC) if this is practical. One option might be to publish a brief update—possibly only for prevalence data and a few other indicators—shortly after new data from these surveys have been published. It is also possible to consider updating PDF versions of country factsheets (available online) between iterations to include any vital key new developments.

Future networking There are some indicators where numerous respondents gave a no response (i.e., suggesting that no schemes exist) but this more accurately meant that no information was available, producing so-called false negatives. The situation analysis found that focal points used different strategies—such as doing their own research, delegating the task—to complete the questionnaire. It is clearly a positive ‘side-effect’ of the data collection that countries have expanded, strengthened and institutionalized national cross-sectoral networks. A number of recommendations for supporting future networking were proposed for discussion:

• Consider ways to support focal points in expanding and intensifying national physical activity networks.

• Consider ways of integrating the focal point network and the HEPA Expert Group.

• Consider cooperation with/support by other international networks. • Consider further scientific support to the focal point network for upcoming

rounds of data collection (e.g. via webinars). Discussion A degree of overlap between the focal point network and the HEPA Expert Group was acknowledged. 10 Participants were reminded that the mandate for the HEPA Expert Group, under the current EU Work Plan, would come to an end in 2017. Focal points’ appreciation of the scientific support provided for the data collection was emphasized and there was a request for further support in the future. The discussion confirmed that cross-sector collaboration remains one of the biggest challenges, and that any support from the European Commission or WHO to help facilitate this, such as an inter-sectoral meeting, would be highly appreciated. Greater collaboration with the EU High Level Group (HLG) on Nutrition and Physical Activity was proposed. It has been agreed that the HLG will not collect its own data on physical activity, rather it will use the data collected by the focal points 10 The Expert Group on HEPA held a meeting the following day, also in Cyprus, and the report is available at http://ec.europa.eu/sport/policy/cooperation/expert-groups-2014-2017_en.htm (table at the bottom: column XG HEPA, report of 12/04/2016).

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network. The Commission intends to organize a joint meeting between the HLG and the focal point network at some point and WHO offered to provide focal points with a list of national HLG representatives. Closer collaboration with the education sector would also be welcomed in the future. Sonja Kahlmeier provided some information about a forthcoming workshop as part of an ERASMUS+ initiative, the European Collaborative Partnership on Sport and Health-Enhancing Physical Activity project. In September 2016 a workshop is planned to support EU focal points with their tasks on Valuing Physical Activity. This aims to present different approaches on how to estimate economic value for physical activity, exploring the economic costs of physical inactivity, best buys for physical activity interventions, and how to evaluate the economic impact of interventions. The project will offer flights and accommodation for EU focal points to support their participation in the workshop, which will take place 27-28 September in Belfast. Further information is available from Professor Charlie Foster at Oxford University (charlie.foster@dph.ox.ac.uk).

Recent developments in promoting physical activity for health in the United Kingdom Beelin Baxter, Department of Health in England, United Kingdom, presented a recent piece of work from the UK to support health professionals in implementation of the UK Chief Medical Officers’ Guidelines Start Active, Stay Active, issued in 2011. A series of factsheets were issued when the Guidelines were launched. When research suggested, however, that health professionals had very little awareness or understanding of the Guidelines, a new initiative was developed. The 10-page factsheets on (a) adults and older adults and (b) children and young people were transformed into single page infographics. These infographics have proved very popular and have been used by health and education professionals in various formats. While the infographic on adults was targeted mainly at health professionals, the children and young people infographic is targeted at both health and education professionals. The infographics are being printed as a special tear-out sheet in the professional journal, BMJ. There is evidence that the infographics have been adopted and used elsewhere. Dutch, Spanish and Portuguese language versions have all been produced. The infographics are available from www.bit.ly/startactive and there are no copyright restrictions on reproduction of the sheets (except a requirement to credit the UK publication). A third infographic, relating to children under five, is in production. This will specifically target health visitors, nurses, paediatricians and child care practitioners. Discussion The infographic was welcomed and the possibility of adapting it into other languages noted.

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WHO Regional Office for Europe has also produced an infographic on physical activity. This is also available for Member States to use and disseminate widely.11

Presentation of the ERASMUS+ Safeyou project, ‘Stay fit, Stay clean’ Vasilis Barkoukis, Aristotle University of Thessaloniki, Greece presented an overview of the Erasmus+ co-funded SafeYou project on strengthening the anti-doping fight in fitness and exercise in youth. This project has explored the use of legal and illegal performance-and-appearance-enhancement substances (PAES). The project found that some people are exercising for appearance rather than health reasons and that these people are more susceptible to use PAES. The SafeYou project found use of illegal PAES use in some samples of exercisers and/or gym-users ranged from 13 to 30%. The project concluded that doping is an emerging public health challenge which is not being addressed by anti-doping authorities or health services. Recreational users may be using PAES for longer uninterrupted periods of time than elite competitors, who are subject to controls, and are using them without any medical supervision or advice. The project has developed an innovative, web-based and user-friendly education tool aimed at adolescents to explain the risks and benefits of these substances. The project has also identified a number of areas where policy-makers can act:

• Identify that there are some risks and include recommendations against use of PAES in communication messages.

• Join forces with the fitness industry (including personal trainers) and engage them in tackling doping use.

• Initiate discussions on how to regulate the channels through which doping substances are promoted and exercisers access substances.

• Support research to better understand this phenomenon. • Support educational interventions and activities to promote ‘safe and drug-

free’ amateur and fitness sports.

Discussion The findings of the project were welcomed as a valuable eye-opener. There was some discussion—and divergent views—about whether there is really sufficient evidence to demonstrate that the issue is an emerging public health concern at this point. Nonetheless, there is great concern about adolescents’ uncontrolled or unsupervised use of these substances—including as a possible gateway to other harmful health behaviours for a group that is normally relatively health conscious. It is an issue that should be borne in mind when developing HEPA policy.

11 Available from http://www.euro.who.int/en/health-topics/disease-prevention/physical-activity/data-and-statistics/infographic-make-physical-activity-a-part-of-daily-life-during-all-stages-of-life

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Presentation of the WHO European database on nutrition, obesity and physical activity (NOPA) database João Breda presented an overview of the revamped NOPA database. The database is in the final phase of construction and testing, but should be launched in coming months. In its new form, the website will combine data on diet, physical activity and other indicators. It will enable data visualizations for various variables. The data from the EU monitoring framework are included, and it will be possible to explore the results on an indicator-by-indicator basis. The database will also be included in the WHO Statistics App, which already incorporates HBSC and COSI data. Focal points are encouraged to use the demonstration copy (a link will be sent to focal points) and to provide feedback.

Conclusions and next steps On behalf of the European Commission, Yves Le Lostecque thanked participants for their contributions. It is clear that a great deal of progress has been made since the network was initiated in Rome in 2014. It is helpful to take stock of achievements at this point in time because this is a key period of decision-making on the future of HEPA policy in the EU. Olivier Fontaine also thanked participants for the interesting and useful exchange of views and outlined some of the next steps. The European Commission and WHO Regional Office for Europe plan to continue this close collaboration and the focal point network will remain a key element. This will be particularly important given that the mandate of the HEPA Expert Group will terminate at the end of this year. On behalf of WHO, João Breda thanked all participants and congratulated the focal points on having formed an effective network. This cooperation is mutually beneficial and brings added value to the Commission, WHO and to Member States. Support to the focal point network will remain the core element of the future EU-WHO collaboration. In future, the collaboration may be expanded to cover other areas—such as the improvement of data quality for physical activity surveillance—and in this way, the network may make an important contribution to physical activity policy at the global level. In order to achieve such global leverage it will be important for the network to maintain the momentum on data collection, and not to leave too long a gap before the second round of questionnaire completion. In order to help focal points complete more frequent data updates, it would be possible to revise the focal points Terms of Reference to fully reflect the work involved in the mandate. WHO is keen to pursue work in new areas including (a) early development issues and a life-course approach, and (b) estimating the costs of physical inactivity and sedentary behaviour. For the latter, a joint collaboration between WHO and OECD is under discussion.

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The concrete next steps were outlined:

• The EU-WHO collaboration will continue and the focal point network will continue to meet twice a year.

• An initial meeting on the study on the different measurement instruments in use is planned for June 2016 to further discuss and plan the field work.

• A further meeting of the focal point network is proposed in 2016—one option would be to synchronise with the HEPA Europe conference and the EHPEPA workshop on Valuing physical activity in Belfast, 28-30 September 2016. The following meeting is likely to take place in January 2017.

• The project will work towards revision of the factsheets in the near future, with a decision on the precise frequency of revision still to be finalized.

Dr Clea Hadjistephanou Papaellina, Chair of the Cyprus Sport Organisation addressed the meeting to express the Board of Directors of the Organisation’s great pleasure to host the meeting. The Board recognises the important role of a modern state in providing facilities and scientific expertise to enable participation in sport and physical activity. She welcomed the network’s efforts to harmonize data collection and reporting in order to promote health-enhancing physical activity. The Cyprus Sport Organization is very open to any further collaboration in the future. She wished participants a pleasant stay in Cyprus. João Breda once again thanked the hosts, the organisers and all participants then closed the meeting.

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ANNEX I: LIST OF PARTICIPANTS AUSTRIA Christian Halbwachs Bundes-Sportförderungsfonds Prinz Eugen Straße 10/8 OG 1040 Vienna BELGIUM Nancy Barette Policy Officer Sport Department of Culture, Youth, Sport & Media, Flanders Pastoor Dewitstraat 33 B-2220 Heist-op-den-Berg Marc Xhonneux Attaché – Legal Affairs Direction Générale du Sport Ministry of the French Community of Belgium Boulevard Léopold II, 144 1180 Brussels BULGARIA Danail Tanev Chief Expert Ministry of Youth & Sports Boulevard Vasil Levski 75 1040 Sofia CROATIA Slaven Krtalić Croatian National Institute of Public Health Rockefeller 12 10000 Zagreb CYPRUS Michalis Michaelides Scientific Director Cyprus Sports Medicine & Research Centre (KAEK) Makario Athletic Centre Avenue Nicosia 1304 24804 Engomi Fani-Anna Poiriazi Physical Education Consultant Cyprus Ministry of Education and Culture Gialousas 1 2480 Tseri

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CZECH REPUBLIC Marie Nejedla National Institute of Public Health Centre for Public Health Promotion Srobarova 48 10042 Praha 10 ESTONIA Margus Klaan Estonian Ministry of Culture Suur-Karja 23 15076 Tallinn FINLAND Paivi Aalto-Nevalainen Cousellor for Cultural Affairs Ministry of Education & culture Meritullinkatu 1, PO Box 29 00023 Helsinki FRANCE Jean-François Toussaint Institut de Recherche bioMédicale et d’Epidémiologie du Sport 11, avenue du Tremblay 75012 Paris Martine Duclos CHU Gabriel Montpied Service de médecine du sport et des explorations fonctionnelles Rue Montalembert 63000 Clermont-Ferrand GERMANY Ute Winkler Head of Division Federal Ministry of Health Friedrichstraβe 108 10117 Berlin HUNGARY Réka Veress Ministry of Human Capacities Szalai u. 3 1054 Budapest ITALY Igor Lanzoni Presidency of the Council of Ministers Sport (Rome), HEPA National Focal Point Via Pecorara 7/20 16011 Arenzano (Genoa)

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LATVIA Kaspars Randohs Senior Desk Officer Department of Sport Ministry of Education and Science of the Republic of Latvia Valnu Street 2 3124 Riga LITHUANIA Arturas Kulnis Chief Specialist Department of Physical Education & Sports under the Government of the Republic of Lithuania Zemaites Str 6 03117 Vilnius LUXEMBOURG Hubert Eschette Ministry of Sport 66, rue de Trèves L-2630 Luxembourg MALTA Robert Portelli Kunsil Malti ghall-Isport Cottonera Sports Complex Cottonera Avenue BML – 9020 Cospicua NETHERLANDS Wanda Wendel-Vos National Institute for Public Health and the Environment (RIVM) Postbus 1 3720 BA Bilthoven POLAND Marek Soltysiak Ministry of Sport & Tourism Republic of Poland ul. Senatorska 14 Warsaw 00-082 Marcin Brzychcy Head of Child and Youth Sport Promotion Unit Department Sport for All 14 Senatorska Str. 00-082 Warsaw

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PORTUGAL Inês Proença Adviser of Secretary of State of Youth and Sport Secretariat of State of Youth and Sport Avenida 5 de Outubro, nº 107, 10º piso 1069-018 Lisbon Paulo Rocha Sport Technician Portuguese Institute of Sport and Youth Rua Rodrigo da Fonseca, 55 1250-190 Lisbon ROMANIA Cirprian Ursu National Institute of Public Health Dr. Anastasievici Leonte Str. Nr.1-3 050463 Bucharest SLOVAKIA Robert Ochaba Public Health Authority Trnavská Cesta 52 826 45 Bratislava Adriana Mičkovicová Department of Education and International Affairs in Sport Ministry of Education, Science, Research and Sport of the Slovak Republic Stromová 1 813 30 Bratislava 1 SPAIN Victoria Ley Director Deputy Director General on Sport and Health Spanish Agency for the Protection of Health in Sport Plaza de Valparaíso 4 28016 Madrid Javier Argaya Amigo Spanish Agency for the Protection of Health in Sport Calle Pintor el Greco S/N 28040 Madrid SWEDEN Marita Friberg Public Health Agency Folkhälsomyndigheten 171 82 Solna

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UNITED KINGDOM Beelin Baxter Department of Health in England 133-155 Waterloo Road SE1 8UG London

OBSERVERS Vasilis Barkoukis Erasmus+, SafeYou Project Aristotle University of Thessaloniki Greece Holger Haubold Policy Officer European Cyclists’ Federation Rue Franklin 28 1000 Brussels, Belgium Rose-Marie Repond Scientific Adviser EUPEA / Federal Institute of Sport – Bern University of Sport Magglingen Buchille 14 1633 Marsens Switzerland

TEMPORARY ADVISERS Peter Gelius Institute of Sport Science and Sport Friedrich-Alexander University Erlangen-Nuremberg Gebberstr. 123b 91058 Erlangen, Germany Sonja Kahlmeier University of Zurich Epidemiology, Biostatistics and Prevention Institute (EBPI) Seilergraben 49 8001 Zurich, Switzerland Alfred Rütten Director Institute of Sport Science and Sport Friedrich-Alexander University Erlangen-Nuremberg Gebberstr. 123b 91058 Erlangen, Germany

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EUROPEAN COMMISSION Yves Le Lostecque Head of Unit – Sport Policy & Programme European Commission Directorate-General for Education and Culture B-1049 Brussels/Belgium Olivier Fontaine Policy Officer European Commission Directorate-General for Education and Culture Unit Sport; Erasmus+ B-1049 Brussels/Belgium

WHO Regional Office for Europe UN City Marmorvej 51 2100 Copenhagen, Denmark João Breda Programme Manager Nutrition, Physical Activity and Obesity Division of Noncommunicable Diseases and Life-course Nathalie Germain Julskov Secretary Nutrition, Physical Activity and Obesity Division of Noncommunicable Diseases and Life-course

RAPPORTEUR Karen McColl 21 Apple Grove, PO21 4NB Bognor Regis West Sussex, United Kingdom