EUROPEAN COMMISSION Brussels, 5.12.2016 COM(2016) 768 final REPORT FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS on the implementation of the Council Recommendation on promoting health-enhancing physical activity across sectors



1.Introduction and context The Council requested the Commission to report on progress on implementing the Council Recommendation on promoting health-enhancing physical activity (HEPA) across sectors (hereinafter referred to as the 'Council Recommendation'), adopted in November 2013, every three years, and on its added value. This progress report covers the 2014-2016 period. Most people in Europe do not reach the minimum levels of physical activity recommended by the World Health Organisation (WHO). In particular, people with low socioeconomic backgrounds, minority ethnic groups, and people with disabilities are not physically active enough. EU Member States acknowledged the need to boost HEPA policies at national level and recognised the benefits of action at EU level, which led to the adoption of the Council Recommendation on HEPA in 2013, based on a proposal from the Commission. More recently, the Council adopted conclusions on the promotion of motor skills, physical and sport activities for young children. It invited Member States to raise awareness of the benefits of regular physical activity from early childhood onwards and to encourage children to be more active by implementing cross-sector policies, for example in the education, youth and health sectors. The Council Recommendation encourages EU Member States to work across sectors and to involve policy areas such as sport, health, education, environment and transport in their national strategies and action plans. It also encourages Member States to cooperate closely with each other and the Commission by regularly exchanging information and best practices. In addition, the Council recognised that more reliable and timely information on the situation across the EU was essential to support national and regional policy-making, and therefore proposed a monitoring framework based on the EU Physical Activity Guidelines(‘the HEPA monitoring framework’). 2.Method The HEPA monitoring framework is composed of 23 indicators covering different thematic areas relevant for HEPA: international physical activity recommendations and guidelines, a cross-sector approach, sport, health, education, environment (including urban planning and public safety), working environment, senior citizens, evaluation, and public awareness. The Council Recommendation called on each EU Member State to appoint a national physical activity focal point to coordinate the collection of information for the HEPA monitoring framework at national level. All 28 EU Member States designated their focal points by mid-2014 and the network of physical activity focal points was launched in Rome in October 2014. Data for use in the HEPA monitoring framework was collected in 2015, in cooperation with the WHO. With the Commission’s support, the network met in January 2015 and June 2015 to share and discuss difficulties encountered, and in April 2016 and September 2016 to discuss lessons learned and future rounds of data collection. In addition, the Commission worked with a consortium of researchers led by the University of Erlangen-Nurnberg (Germany) to provide the focal points with assistance on the HEPA monitoring framework. The consortium also carried out an independent assessment of the monitoring framework and of the process (HEPA study). As part of this study, a specific situation analysis was conducted in several countries, to collect feedback, lessons learned and suggestions related to the implementation of the HEPA monitoring framework, and to provide the Commission with recommendations for improving different elements of the monitoring framework and of the support provided to Member States. This progress report is based on contributions from the Member States, received mainly through the network of physical activity focal points and from the WHO. The report builds on the HEPA study mentioned above. 3.WHO database on Nutrition, Obesity and Physical Activity (NOPA) and country factsheets on HEPA All data collected through the HEPA monitoring framework fed into the existing WHO European database on nutrition, obesity and physical activity (NOPA). NOPA’s main components are epidemiological and prevalence data, policy actions and good practices related to nutrition, obesity and physical activity. The Commission supported the WHO’s further development of the physical activity parts of the database, to adapt it to the HEPA monitoring framework and to improve the user interface. The Commission supported and closely cooperated with the WHO Regional Office for Europe to compile Member States’ contributions into country factsheets on HEPA. These factsheets were released at the occasion of the European Week of Sport in September 2015. They present country-specific overviews on HEPA (including good practices), and include an analysis of HEPA trends and situation in the EU. The WHO Regional Office for Europe reported that in May 2016 the country factsheets ranked in the top 20 products consulted on the WHO’s website. 4.HEPA policy development and implementation at national level In this first round of data collection under the HEPA monitoring framework, 27 of 28 EU countries took part in the survey on implementing the 23 indicators. The data collected presents a good overview of the state of play of HEPA promotion in the EU. It can be consulted in the WHO’s NOPA database. An overview is provided in the country factsheets on physical activity published by the WHO Regional Office for Europe and the Commission. Following the adoption of the Council Recommendation in November 2013, all 27 respondent countries have developed national policies or action plans in one or more of the sectors covered by the HEPA monitoring framework. Notably, Member States adopted new policies in the sport sector (13 Member States), the health sector (10 Member States), the education sector (8 Member States), in the environment, urban planning and public safety sector (including transport; 3 Member States) and in the senior citizens sector (3 Member States). However, of the 152 policies and action plans reported, many had already started before the Council Recommendation was adopted. An indicator is considered implemented when a Member State has introduced a policy or programme that is tracked using the indicator. There are 23 indicators in the monitoring framework; 23 countries have implemented 10 or more indicators, while five countries have implemented 20 or more. Only one country fully addressed and implemented all 23 indicators of the monitoring framework. It is notable that only seven countries have implemented policies covering all thematic areas of the monitoring framework. The figure below illustrates the number of indicators implemented by 27 EU Member States.

An overview of the results of the HEPA monitoring framework by thematic area is presented below. National policy recommendations on physical activity for health have been put in place by 19 countries. Of these, 18 target adults, 17 address young people and 16 are aimed at older adults. In 10 countries, the national recommendations were based on the WHO recommendations. One country’s recommendations followed the EU’s physical activity guidelines. Eight countries followed other international recommendations or a combination of them. A total of 16 countries reported having a fully developed and implemented specific national coordinating mechanism for promoting HEPA. One country reported strong cross-ministry cooperation which had the same effect as a coordinating mechanism, and four more countries plan to introduce a mechanism within two years. National ‘sport for all’ policies were implemented in 22 countries. Seven countries implemented policies that were not dedicated exclusively to ‘sport for all’, but included ‘sport for all’ as one of the topics. ‘Sport clubs for health’ programmes (which encourage sport clubs to invest in health-related sport activities and in promoting health as linked to sport activities) were implemented in seven countries. Two more countries plan to implement such programmes in the near future. Some countries addressed the needs of more than one target group in an integrated way, while others addressed particular target groups depending on the HEPA sector. In particular, 10 countries reported having implemented specific frameworks to support access to recreational or exercise facilities for socially disadvantaged groups (immigrants or socially vulnerable people). Two Member States focused more on using sport as an integral component of rehabilitation and reintegration programmes for disabled people. HEPA policies were implemented in the health sector in 22 countries. Training on physical activity was included in curricula for health professionals in 17 countries. In 14 countries, physical activity was included in training modules for doctors and physiotherapists; in eight countries it was included in training modules for nurses. In addition, 13 countries put in place programmes to promote physical activity counselling by health professionals. These programmes related mostly to preventing non-communicable diseases and provided guidance to health professionals, sometimes in the form of free online courses. In 19 countries, HEPA policies were implemented in relation to the environment, urban planning, and public safety (including transport). Walking was reported to be among the three main modes of transport for daily activities in 20 countries; cycling was among the top three in eight countries. Furthermore, some countries introduced measures such as tax incentives (e.g. VAT refunds on bikes purchased, tax exemptions and/or employee compensation for walking or cycling to work), high parking fees and congestion charges. 14 countries reported having implemented active travel-to-work schemes (one more plan to do so in the near future), while 12 countries put in place schemes to encourage physical activity in the workplace (six more plan to do so in the near future). Four countries reported having implemented the European guidelines for improving infrastructure for leisure-time physical activity at national level, and six more countries plan to do so in the near future. HEPA policies were implemented in the education sector in 19 countries. While all Member States implemented a measure that requires a certain number of mandatory physical education hours in schools (varying from one to almost five depending on the grade and country/region), six countries allowed for a combination of mandatory and optional physical education classes in primary schools, and five allowed this in secondary schools. Several countries also reported having implemented various school-related HEPA promotion programmes: active breaks between lessons (eight countries), active breaks during school lessons (four countries), and extra-curricular activities (11 countries). To encourage active travel to school, nine countries reported having implemented programmes with measures to make cycling and walking to school safer. HEPA was included in the training of physical education teachers in 20 countries. Community interventions to promote physical activity among senior citizens were reported in 13 countries, including two countries with plans to implement such projects in the near future (e.g. programmes to strengthen older adults’ balance and coordination, including frailty and fall prevention, education and exercise counselling). Successful communication campaigns to raise public awareness of the benefits of physical activity and to increase the number of people who are physically active were reported by 18 countries. One country reported as many as 14 different campaigns. While some campaigns targeted all citizens, others were aimed at vulnerable groups, such as children or senior citizens. The outreach of the campaigns was sometimes nationwide, while at other times it was limited to a region or city. 5.Measuring the prevalence of physical activity Monitoring trends and changes in the population’s level of physical activity over time is important for developing, evaluating and improving national policies on physical activity. Under the HEPA monitoring framework, physical activity levels in the EU Member States were reported as percentages of adults, children and adolescents who were reaching the minimum levels of physical activity recommended by the WHO. Systems to monitor the population’s physical activity levels were reported to be in place in 17 Member States (5 more are expected within two years). However, these systems were based on a variety of different survey instruments and questionnaires. Furthermore, several countries reported data on physical activity levels from more than one source or instrument. 12 countries provided data on adults’ physical activity levels from independent national studies. Data from EU surveys were also reported (six countries reported Eurobarometer data and two countries used European Health Interview Survey results as their national data on physical activity levels). One country also reported data from the objective measurement of physical activity, using devices such as accelerometers. Data for children and adolescents mostly came from the Health Behaviour in School-aged Children survey, which provides a largely accepted standardised source of data for international comparisons and observation of trends, or from nationally representative studies. Where no national data were available, estimates of physical activity levels were extracted from the WHO’s Global Health Observatory. The reported data revealed big differences within and between countries, depending on the survey instruments and methodologies used. Notably, there were significant differences between data obtained via some national surveys, EU surveys such as the Eurobarometer and the European Health Interview Survey, and especially the WHO Global Health Observatory estimates. Member States reported that they were aware of this issue and the related difficulties with ensuring the validity and comparability of physical activity data in the EU. The publication of contradictory data from different survey instruments was identified as a concern for the promotion of physical activity, and as an issue that needs to be addressed. 6.Cooperation on HEPA between Member States and with the Commission The Council Recommendation encourages Member States to cooperate closely among themselves and with the Commission on promoting HEPA, by engaging in a process of regular exchange of information and best practices. The Commission was invited to facilitate these exchanges and to support the Member States in their work in this area. The Expert Group on Heath-Enhancing Physical Activity, set up under the EU Work Plan for Sport 2014-2017, was charged with coordinating the implementation of the Council Recommendation. Presentations of good practices in promoting HEPA (including EU funded research), from Member States and observer organisations, were systematically included in the meetings, to facilitate the exchange of experience and lessons learned. In addition, the expert group compiled a set of good practices from all Member States and sport organisations who attended the meetings as observers. This was to provide inspiration for those countries that are in the process of developing or modifying their national strategies and policies. The network of focal points also created opportunities to exchange information and for peer-learning (various presentations from Member States were systematically included in the network’s meetings as well).

The Commission supported the WHO in providing technical assistance to several Member States who were developing and implementing national physical activity guidelines. More specifically, it supported the development and implementation of a toolkit that aims to improve the promotion of HEPA in primary health care settings in Croatia, and the development of a national strategy on physical activity in Malta and Portugal. In addition, the sport chapter of the Erasmus+ Programme, which covers the 2014-2020 period, includes in its objectives the promotion of awareness of the importance of HEPA, through increased participation in and equal access to sport for all. In 2014 and 2015, the EU co-financed a total of 26 collaborative partnerships aiming to encourage participation in sport and physical activity. These projects were implemented in a significant number of Member States, thus reaching out to the European citizens in their local environments, and targeted various sections of the population, including children, the elderly and people with disabilities. The Erasmus+ programme supported the efforts of a variety of stakeholders coming from academia, public authorities, NGOs and sport clubs in implementing the EU physical activity guidelines in the Member States. Finally, Member States and the Commission also work together in the context of the European Week of Sport, a Europe-wide initiative launched in 2015 and aiming to raise awareness of the benefits of sport and physical activity, regardless of age, background and fitness level. Five partnerships were co-financed in the context of the European Week of Sport in 2015, and eight in 2016. The first two editions were successful. 31 European countries were involved, and the initiative was organised in partnership with major sport and sport-related organisations, who committed to organising events and more generally to promoting physical activity. The European Capitals and Cities of Sport Federation, who decides on the European Capital and Cities of Sport awards every year, was among these partners. 7.European statistics on physical activity As sport has gained an important place in European strategies and programmes, there is an increasing need for harmonised and comparable statistics to strengthen evidence-based policies in this field. The Council Recommendation invited the Commission to examine the possibility of producing European statistics on physical activity levels based on data collected under the HEPA monitoring framework. In 2016, Eurostat and the Commission started to disseminate harmonised statistics on physical activity performance, based on already existing EU surveys. In particular, the European statistical programme for 2013-2017 sets out the provisions under which statistics on physical activity are to be provided. In 2016, data on physical activity levels and the practice of sport, fitness and recreational activities will be disseminated from the second edition of the European Health Interview Survey (EHIS) and the Time Use Surveys.Under the current public health statistics framework regulation, the third edition of the EHIS survey is planned for 2019; subsequent surveys will be carried out under the upcoming regulation on social microdata survey collections, which will increase their frequency from five to six years. Eurostat, the Commission and the Member States are working together to agree on the survey instruments. In the context of the HEPA monitoring framework, only two Member States used data from EHIS to report on physical activity levels. The main limitation of this survey is that it does not include slow recreational activities. Furthermore, it does not assess to what extent the WHO’s recommendations on physical activity are met by the population, as is required under the HEPA monitoring framework. Such limitations have to be addressed if the EHIS survey is to be used as a uniform physical activity monitoring tool across the EU. 8.Evaluation of the Council Recommendation’s added value The Council Recommendation provided Member States with an impetus to address physical inactivity through public policy. Of the total 152 policies and actions plans reported by the Member States across all sectors relevant for HEPA promotion, 37 were adopted after the Recommendation was adopted in November 2013. It can be expected that the WHO’s Physical Activity Strategy for the European Region 2016–2025 will further strengthen the incentive for Member States to act in this area. The Council Recommendation also contributed to improving the monitoring of health-enhancing physical activity in the EU Member States, from epidemiological data to policy developments. As a result, several countries have expanded, intensified or even formalised their national cross-sector networks, or plan to do so in the future. The data collected under the HEPA monitoring framework provided, for the first time, an overview of the implementation of HEPA-related policies and actions across the EU. This information made it possible to compare the state of play of HEPA policy implementation between EU Member States and facilitated the exchange of good practice, providing inspiration for those countries that are in the process of developing or modifying their national strategies and policies. The outcomes will benefit national authorities and stakeholders as they identify policy needs and progress. The data collected under the HEPA monitoring framework are also useful for some of the monitoring indicators on physical activity in the Member States’ Action Plans on Childhood Obesity. The first round of monitoring constitutes a baseline against which subsequent rounds of monitoring will be assessed to measure evolution and progress. Using evaluation plans to assess the impact and effectiveness of policies and action plans at national level is crucial. Out of 152 reported policies or action plans, most (116) contained an evaluation plan. However there was no information reported on whether these evaluations were carried out. Overall, the focal points’ contributions to the HEPA monitoring framework were good, which should be considered very positive for a first round of monitoring. For future rounds of data collection, it will be useful to modify the survey instrument for several indicators and to define some indicators more precisely to reduce the margin for interpretation (e.g. which status guidelines should have to be reported). This would make it possible to perform better cross-country data comparisons. The assessment of the first round of monitoring reveals specific national contexts and problems that arose when respondents answered the survey. First, the cross-sector nature of the HEPA monitoring framework remains a possible challenge. Focal points could have missed some information at national level because they did not have the relevant network contacts or resources outside of their own sector. Secondly, some schemes and policies are implemented not by national governments but mostly at regional or local level (e.g. in federalist countries), or have to be implemented by stakeholders who do not report back to governments. The monitoring exercise did not explore in detail any achievements at regional and local level. Future rounds of monitoring under the HEPA monitoring framework could be improved to better capture efforts at these levels. Thirdly, Member States provided some information on HEPA funding but, as financial support for HEPA comes from different policies and budget lines at national level or from several levels of government, thorough reporting on this indicator was not possible at this stage. The structured cooperation with the WHO in the context of the Council Recommendation has proved to be mutually beneficial, and included joint dissemination activities and improvement of the NOPA database. In particular, the focal points found the support provided by the Commission, WHO and the scientific experts useful. The Commission received positive feedback on the country factsheets from the focal points and the Council Working Party on Sport. The factsheets’ content and format were both considered to be appropriate. It was suggested that the factsheets be revised every three years, as this would make it possible to follow up planned schemes and policies in a timely way. 9.Conclusions This review of the implementation of the Council Recommendation for 2014-2016 shows several positive developments, including: the adoption of many new policies and action plans at national level; the strengthening of cross-sector cooperation at national level; improvement of monitoring at national level; provision of an overview of HEPA-related policies and actions in the EU which serves as a very rich source of data for further analysis; and improved cross-border cooperation based on an exchange of best practices. Ultimately, the success of promoting HEPA largely depends on Member States’ capacity to implement the Council Recommendation effectively across sectors, and to offer citizens a framework that favours an active lifestyle. The Commission will, however, also further strengthen its cooperation with key stakeholders in the Member States. The data collected makes it possible to identify gaps in public policies at national level. Nevertheless, assessing the impact and effectiveness of existing policies and action plans at national level also remains crucial. This requires reliable data on the levels of physical activity in the population. The publication of contradictory data from different survey instruments was identified as an issue that needs to be addressed.