COMMISSION STAFF WORKING DOCUMENT A monitoring framework for the implementation of policies to promote health-enhancing physical activity (HEPA), based on the EU Physical Activity Guidelines Accompanying the document Proposal for a Council Recommendation on promoting health-enhancing physical activity across sectors
Date: 2013-08-28
Institutions: European Commission
Subjects: EU financing, European cooperation, World Health Organisation, approximation of policies, health care, physical education, primary education, public awareness campaign, secondary education, sport













EUR-Lex - 52013SC0310 - EN











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52013SC0310

COMMISSION STAFF WORKING DOCUMENT A monitoring framework for the implementation of policies to promote health-enhancing physical activity (HEPA), based on the EU Physical Activity Guidelines Accompanying the document Proposal for a Council Recommendation on promoting health-enhancing physical activity across sectors /* SWD/2013/0310 final */









TABLE OF CONTENTS
1........... INTRODUCTION........................................................................................................ 4
2........... INDICATORS ON THEMATIC AREAS OF
THE EU PA GL..................................... 5
2.1........ Definitions...................................................................................................................... 5
2.2........ Overview of work carried out......................................................................................... 6
2.3........ Overview of indicators for the
monitoring of the implementation of the EU PA GL............ 9
2.4........ Operationalization, methodology
and data by indicator................................................... 14
2.4.1..... Indicator 1: National
recommendation on physical activity for health............................... 14
2.4.2..... Indicator 2: Adults reaching the
minimum WHO recommendation on physical activity for health            15
2.4.3..... Indicator 3: Children and
adolescents reaching the minimum WHO recommendation on physical activity for
health.................................................................................................................................... 18
2.4.4..... Indicator 4: National coordination
mechanism on HEPA promotion................................ 19
2.4.5..... Indicator 5: Funding allocated
specifically to HEPA promotion....................................... 20
2.4.6..... Indicator 6: National Sport for
All policy or action plan.................................................. 21
2.4.7..... Indicator 7: Sport Clubs for
Health Programme............................................................. 22
2.4.8..... Indicator 8: Framework to support
offers to increase access to exercise facilities for socially disadvantaged
groups.................................................................................................................................... 23
2.4.9..... Indicator 9: Target groups
addressed by the national HEPA policy................................. 25
2.4.10... Indicator 10: Monitoring and
surveillance of physical activity.......................................... 26
2.4.11... Indicator 11: Counselling on
physical activity................................................................. 27
2.4.12... Indicator 12: Training on physical
activity in curriculum for health professionals............... 27
2.4.13... Indicator 13: Physical education in
primary and secondary schools................................. 29
2.4.14... Indicator 14: Schemes for
school-related physical activity promotion.............................. 30
2.4.15... Indicator 15: HEPA in training of
physical education teachers......................................... 31
2.4.16... Indicator 16: Schemes promoting
active travel to school................................................ 32
2.4.17... Indicator 17: Level of cycling and
walking..................................................................... 33
2.4.18... Indicator 18: European Guidelines
for improving Infrastructures for Leisure-Time Physical Activity       34
2.4.19... Indicator 19: Schemes to promote
active travel to work................................................. 36
2.4.20... Indicator 20: Schemes to promote
physical activity at the work place............................. 37
2.4.21... Indicator 21: Schemes for community
interventions to promote PA in elderly people....... 38
2.4.22... Indicator 22: National HEPA
policies that include a plan for evaluation........................... 39
2.4.23... Indicator 23: National awareness
raising campaign on physical activity........................... 40
3........... Key information sources............................................................................................... 41
1.           INTRODUCTION
In its 2011 Communication on sport[1] the European Commission noted
that physical activity is one of the most important health determinants in
modern society, that there are large differences in physical activity levels
and public approaches between Member States and that the concept of health-enhancing
physical activity (HEPA), covering a variety of sectors poses considerable
challenges. To address the physical inactivity trend in Europe and to support
the design and implementation of national physical activity guidelines the
Communication announced a new EU policy initiative to promote HEPA, based on
the EU Physical Activity Guidelines[2]
including a review and coordination process. 
Following this announcement, the Commission
has consulted widely[3]
and, with the help of experts representing a variety of disciplines, has prepared
the core elements for such a proposal. 
According to literature and expert opinion
and as confirmed in the preparatory work for this initiative, the Impact
Assessment in particular, an effective promotion of HEPA should be based on an
approach involving several relevant policy sectors (cross-sectoral approach)
and should involve provisions for monitoring and evaluation. The availability
of data to assess changes in the conditions that affect physical activity is recognised
as being of value in guiding policy and practice.[4] However, data that provides
information on HEPA policies and interventions across many different sectors
(e.g. sport, health, education, transport, etc.) is scarce or not made
available in many EU Member States.
In November 2012, the Council, in its
conclusions on HEPA, endorsed the idea of a new policy initiative based on the
EU Physical Activity Guidelines and called on the Commission to make a proposal
for a Council Recommendation on HEPA, including a light monitoring framework.[5] 
This Staff Working Document (SWD)
accompanies the Commission's proposal and contains two elements:
·                        
An overview of
indicators developed for the monitoring of the implementation of the proposed
Council Recommendation on HEPA, which are based on thematic areas of the EU
Physical Activity Guidelines (henceforth: EU PA GL);
·                        
Additional information on the main existing information sources, databases and publications with
relevance for the monitoring framework.
The SWD thereby aims at providing further
details on the monitoring framework, in particular on the choice of the 23 indicators
listed in the annex to the Commission’s proposal for a Council Recommendation
as well as on the information sources based on which the data should be
collected.
The main input for this document is based
on the work of a study team consisting of Economisti Associati srl (Lead Firm),
The Evaluation Partnership (Partner), University of Zurich (sub-contractor), VU
University Medical Center, Amsterdam (sub-contractor), which assisted the
Commission in preparing its proposal for the monitoring framework. Special
thanks are due the Institute for Social and Preventive Medicine, Zurich for the overall coordination of the development of the monitoring framework. The
suggested approach, in particular the proposed indicator table has received
further input from national and international experts in the field of HEPA and
has been discussed within different fora at the EU level, including the EU
structures for sport and for health. 
2.           INDICATORS
ON THEMATIC AREAS OF THE EU PA GL
The proposed HEPA monitoring framework is
based on the EU PA GL and the table of indicators annexed to the Commission's
proposal for a Council Recommendation contains 23 indicators that relate to all
thematic areas of the 41 EU PA GL. The sections hereafter explain the main
steps and considerations that led to the choice of these indicators and provide
detailed information on each of them with regard to their operationalization
and data sources. 
2.1.        Definitions
Policy development and implementation
comprises different elements which ideally should be captured by a
comprehensive monitoring. In general, four different aspects of policy can be
distinguished[6].
They form an important part of the work basis for the proposed monitoring
framework, and it is useful to reiterate these definitions here.
·                        
Process –
comprising e.g. agenda-setting and formulation of a policy as well as
administrative arrangements (coordination mechanisms to foster cross-sectoral
cooperation, funding, responsibilities, budget, etc.);
·                        
Outputs – all
physical, informal or service products of a policy, such as programmes,
community projects, information campaigns or courses carried out, coordination
groups formed, etc., as well as the existence of a policy itself;
·                        
Outcome –
directly policy-related changes in conditions, e.g. raised awareness,
knowledge, political commitment or capacity to address the issue (e.g. in terms
of new workforce trained) and change in behaviours;
·                        
Impacts –
totality of - intentional or unintentional - effects, including also more
distal changes, e.g. health effects.[7]

Most of the proposed indicators are process
or output-related. As indicators are a commonly used tool to assess the process
and results of policies and programmes, it is also important to bear in mind
the key principles for a “good” indicator, including[8]: 
·                        
Validity – it
measures what it is supposed to measure, and at the desired level;
·                        
Clarity – it is
unambiguous and clear what data is needed to measure it
·                        
Objectivity –
anyone reviewing the indicator should reach the same conclusion about progress;
·                        
Sensitivity – it
is able to capture change at a realistic level, and for different sub-groups,
if relevant;
·                        
Action orientation – it is addressing issues that are of relevance to the topic and
amenable to change;
·                        
Feasibility – the
necessary data is available and accurate or affordable to collect.
2.2.        Overview of work carried out
The first step carried out by the
contractor consisted of identifying successful national strategies, of
collating relevant recent work through desk research as well as of
familiarization interviews. This work addressed, amongst others, experiences
regarding evaluation and monitoring of national policies relevant to the EU PA
GL, problems that have prevented optimum implementation of the EU PA GL as well
as expectations and concerns regarding monitoring and evaluation of the EU PA
GL. 
In addition, available information sources
and databases of relevance with regard to monitoring and evaluation of the EU
PA GL where collated. The work revealed several relevant existing information
sources and one key database, namely the WHO Regional Office for Europe’s Nutrition, Obesity and Physical Activity (NOPA) database. 
As a second step the scope, objectives and
expected results of the evaluation of the implementation of the EU PA GL were
defined. As presented above, a monitoring scheme could have predominantly
focused on process and output, or also try to address outcome and impacts. In addition,
the level of detail as well as direct attribution of Member States actions to
the EU PA GL needed to be taken into account. Based on that work, three
possible approaches to develop indicators for the monitoring of the EU PA GL
were identified: 
(a)         
Indicators on direct effects of the EU PA
GL
This would consist of a monitoring of action
taken by Member States as a direct effect of the EU PA GL
(b)         
Indicators on thematic areas of the EU PA
GL
This would include a limited number of
indicators covering the thematic areas of the GL, but not covering every single
guideline.
(c)         
 Detailed indicators on all 41 guidelines
This would include a detailed monitoring of the
implementation of all 41 guidelines of the EU PA GL. 
Direct attribution of EU Member States’
actions to the EU PA GL as foreseen in approach A) would have faced a number of
conceptual, methodological and logistical difficulties and limitations. With
regard to approach C), it was considered unlikely that all Member States would
implement all 41 sub-guidelines of the EU PA GL universally due to different
political priority setting, cultural approach to HEPA promotion and available
resources. Following the work on the Impact assessment accompanying the
Commission's proposal, it was decided that indicators on the implementation of
the EU PA GL for inclusion in a future Council Recommendation on HEPA should
focus on a more aggregate level of information and more general aspects that
can be expected to be more universally addressed by most or all EU Member States.

In addition, an initial analysis of the EU
PA GL also revealed that many of the 41 Guidelines did not lend themselves
easily to the development of specifically related indicators. Oftentimes, the
guidelines contained several elements that would need to be addressed by
different indicators. This was likely to lead to a very high total number of
indicators. Moreover, not all Guidelines had been formulated specifically and
unambiguously enough to be directly measurable. Therefore, approach C) was
considered both impractical and methodologically problematic. 
Subsequently, it was decided to develop indicators
on thematic areas of the EU PA GL as proposed in approach B), leading both to a
manageable number of indicators and an acceptable level of detail with regard
to monitoring the implementation of the EU PA GL.[9] 
The third step of the work focused on
developing a finalised list of proposed indicators including a detailed
description of the proposed methodology for their collection. The availability
of information and data sources turned out to be an important aspect to be
considered, in light of Member States limited resources to invest in burdensome
data collection. 
The list of indicators was developed with
the input of experts and consulted in expert fora, with the policy level and
with stakeholders, in particular at the following EU level meetings:
·                        
Workshop on indicators, 29 February 2012, Brussels;[10]
·                        
2nd and 3rd meeting of the
Expert Group "Sport, Health and Participation" (XG SHP), 21 March and
27 June 2012;
·                        
Informal meeting of EU Sport Directors, 31 May –
1 June 2012;
·                        
Meeting of the High-level Group on Nutrition and
Physical Activity, 14 June 2012[11];
·                        
Expert seminar at EU Sport Forum 2012 in Cyprus, 19 September 2012[12].
These comments as well as those received in
the Commission's inter-service work were taken into account in the present list
of indicators as presented in the Commission’s proposal for the Recommendation
and in this SWD.
The work carried out at expert level lead
to the conclusion to not include a number of potential indicators. The reasons
are laid down in the annex to the Impact Assessment accompanying the
Commission's proposal. As appropriate, and following a first evaluation of the
monitoring framework, indicators could be refined and possible new indicators
could be defined.
2.3.        Overview
of indicators for the monitoring of the implementation of the EU PA GL
The table below summarises the proposed
list of indicators on the thematic areas of the EU PA GL. As the EU PA GL are
mainly addressed to the national administration or other public authorities,
indicators usually address this level and not actions or knowledge of all
possible stakeholders or the general public. Exceptions were only made where
thematic areas of the Guidelines specifically named responsible stakeholders
outside the administration. In some cases, possible integration of sub-national
information is considered in view of the decentralized political and government
structure of some Member States with regard to sport or health. 
Table 1 – Proposed indicators to
evaluate the implementation of the EU Physical Activity Guidelines 
 Thematic areas of the GL || Proposed indicators || Variables/units || Sources 
 “International PA recommendations and guidelines” (guidelines 1-2) || 1.     National recommendation on physical activity for health || Yes/no || NOPA 
 2.     Adults reaching the minimum WHO recommendation on physical activity for health || Percentage of adults reaching a minimum of 150 minutes of moderate-intensity physical activity per week, or 75 minutes of vigorous-intensity activity, or an equivalent combination || European Health Interview Survey (EHIS) or WHO global health data observatory Information on national surveys: NOPA 
 3.     Children and adolescents reaching the minimum WHO recommendation on physical activity for health || Percentage of children and adolescents reaching at least 60 minutes of mode-rate- to vigorous-intensity physical activity daily or on at least 5 days / week || Health behaviour in school-aged children survey (HBSC) 
 “Cross-sectoral approach“ (guidelines 3-5) || 4.     National coordination mechanism on HEPA promotion || Yes/no; if yes: -   Name? Since when in place? -   Which sectors and stakeholders are participating (pre-defined list) -   Which is the leading institution? -   Has funding been allocated to this coordinating mechanism? If yes: o      total funding; o      per capita; o      by gross domestic product at PPP per capita, in Euros || WHO/EC Monitoring project (all items but information on funding can be included in the future) 
   || 5.     Funding allocated specifically to HEPA promotion || By sector (health, sport, transport etc.): -       total funding; -       per capita; -       by gross domestic product at PPP per capita, in Euros || HEPA PAT for 5 EU countries Future monitoring by Expert Group 'Sport, Health and Participation' 
 “Sport” (guidelines 6-13) || 6.     National sport for all policy and/or action plan || Yes/no; if yes: name, status, issuing body, policy areas covered, web-link. || NOPA   
   || 7.     Sport Clubs for Health Programme || Implementation of the guidelines developed by HEPA Europe/TAFISA project: yes/no; if yes, description || Future monitoring by EU Expert Group 'Sport, Health and Participation'* 
   || 8.     Framework to support opportunities to increase access to recreational or exercise facilities for low socio-economic groups || Existence of a framework: yes/ foreseen within the next 2 years/no; and if yes, description || WHO/EC Monitoring project+ (in the future also foreseen to ask on existences of a specific framework) Guidelines developed by IMPALA project§ 
   || 9.     Target groups addressed by the national HEPA policy || By target group (groups in particular need of physical activity (e.g. low socio-economic groups, people with low levels of PA, elderly, ethnic minorities etc.) || NOPA (except for people with low levels of PA; this could be included in the future) 
 ”Health” (guidelines 14-20) || 10.  Monitoring and surveillance of physical activity || Physical activity included in the national health monitoring system: yes/no If yes: name of the survey, year, measured items, age groups, socioeconomics, link to survey || WHO/EC Monitoring project+ 
   || 11.  Counselling on physical activity || Counselling on physical activity: yes / no If yes: reimbursed as part of primary health care services: yes/no || Partly in NOPA (information on existence of a scheme, but not yet on reimbursement, this could be included in the future) 
   || 12.  Training on physical activity in curriculum for health professionals || - number of hours for nurses, doctors¨ - mandatory or optional - clear assessment and accreditation structures to reflect the learning outcomes of the subject || Partly in WHO/EC Monitoring project+ (hours not collected but foreseen to be pilot-tested in next data collection) 
 ”Education” (guidelines 21-24) || 13.   Physical education in primary and secondary schools || - number of hours per school level - mandatory or optional - national or sub-national regulation || Eurydice reporting WHO/EC Monitoring project+ (hours not yet collected but foreseen to be pilot-tested in next data collection) 
 14.  Schemes for school-related physical activity promotion || Existence of a national or sub-national (where relevant#) scheme Yes/no - active school breaks - active breaks during school lessons - after-school HEPA programmes (at schools, at sport clubs, in communities) || Not yet available, future monitoring by Expert Group 'Sport, Health and Participation'* 
 15.  HEPA in training of physical education teachers || HEPA being a module in training of PE teachers at bachelor's and/or master's degree level: yes/no; mandatory/optional || Partly in WHO/EC Monitoring project+ (relating to teacher training to promote PA in general, new information foreseen to be pilot-tested in next data collection 
 16.  Schemes promoting active travel to school || National or sub-national (where relevant#) schemes to promote active travel to school (e.g. walking buses, cycling): Yes/no, if yes: description || WHO/EC Monitoring project+ (information on existence of a scheme, but further information as provided by countries) 
 “Environment, urban planning, public safety” (guidelines 25-32) || 17.  Level of cycling / walking || Main mode of transport used for your daily activities (car, motorbike, public transport, walking, cycling, other) || Flash Eurobarometer or EHIS (wave 2) 
   || 18.  European Guidelines for improving Infrastructures for Leisure-Time Physical Activity || European Guidelines for improving Infrastructures for Leisure-Time Physical Activity (addressing sport infrastructure, leisure-time infrastructure and urban and green spaces) being applied systematically to plan, build and manage infrastructures: Yes / not yet but foreseen within the next 2 years / no || Guidelines developed by IMPALA project§ Future monitoring by Expert Group 'Sport, Health and Participation'* 
 “Working environment” (guidelines 33-34) || 19.  Schemes to promote active travel to work || Existence of a national or sub-national (where relevant#) incentive scheme for companies or employees to promote active travel to work (e.g. walking, cycling): yes/no, if yes: description || WHO/EC Monitoring project+ (information on existence of a scheme, but further information as provided by countries) 
   || 20.  Schemes to promote physical activity at the work place || Existence of a national or sub-national (where relevant#) incentive scheme for companies to promote physical activity at the work place (e.g. gyms, showers, walking stairs etc.): yes/no   || Partly in WHO/EC Monitoring project+ Exchange to be sought with WHO Global Plan of Action on Workers’ health 2008-2014 
 ”Senior citizens” (guidelines 35-37) || 21.  Schemes for community interventions to promote PA in elderly people || Existence of a scheme for community interventions to promote PA in elderly people Yes/no, if yes: description || Initial information collected through EUNAAPA project in 15 countries in 2007/2008° Possible future information from 2012 EC-funded projects "European Partnerships on Sport" (active ageing) Future monitoring by Expert Group 'Sport, Health and Participation'* 
 “Indicators/evaluation” (guideline 38) || 22.  National HEPA policies that include a plan for evaluation || x out of y national HEPA policies (sport, health, transport, environment, by sector) include a clear intention or plan and plan for evaluation || Based on national policies in NOPA database, complemented by sector-specific targeted information collections 
 “Public awareness” (guideline 39) || 23.  Existence of a national awareness raising campaign on physical activity || Yes/no, if yes: description || WHO/EC Monitoring project+ 
#               Sub-national level only for countries
with a decentralized or federal structure, otherwise only national level will
be considered.
*              Not yet included in
monitoring by the EU Expert Group 'Sport, Health and Participation' but could
possibly be included in the future with limited additional reporting burden to
Member States.
ª                       The Sport Clubs for Health Programme
Guidelines were developed as a joint HEPA Europe/TAFISA project supported under
the Preparatory action in the field of sport in 2010 (see also
http://www.kunto.fi/en/home/). 
+                      Information collected in the country
information templates for the WHO/EC project on “Monitoring progress on
improving nutrition and physical activity and preventing obesity in the EU”,
but the information is not yet directly available in the NOPA database (i.e. it
is available offline in the templates as completed by the national focal points
in 2008/9).
°              For more information see
http://www.eunaapa.org. Initial inventory of good practices and recommendations
compiled as part of the EC-funded EUNAAPA project in 2007/2008 in 14 EU MS and Norway, available at
http://www.eunaapa.org/media/cross-national_report_expert_survey_on_pa_programmes_and_promotion_strategies_2008_.pdf.

§                      For more information on the EC-funded project
"Improving infrastructure for leisure time physical activity in the local
arena" (IMPALA) see: http://www.impala-eu.org/fileadmin/user_upload/IMPALA_guideline_draft.pdf 
#               For more information see project on
"Building Policy Capacities for Health Promotion through Physical Activity
among Sedentary Older People” (PASEO), funded by the Public Health programme in
2009-2010, http://www.paseonet.org and
http://ec.europa.eu/eahc/documents/news/PASEO_National_Alliances.pdf.
2.4.        Operationalization,
methodology and data by indicator
In this
section the proposed methodology for each of the 23 indicators is described in
more detail. The key data sources are presented in chapter 3. 
2.4.1.     Indicator
1: National recommendation on physical activity for health
What does this indicator tell us?
National
recommendations on how much physical activity the population should carry out
to achieve health benefits serves as a benchmark for progress made to promote
physical activity and is an important element of a national strategy to promote
physical activity.
Definitions and operationalization
A national
recommendation on physical activity and health is an officially adopted
national statement on the duration, intensity and frequency of physical
activity behaviour that the population should reach. Recommendations issued by
non-governmental bodies, which have not been officially endorsed by the
national government, are not considered a national recommendation. Sub-national
recommendations are only included for countries with a decentralized government
structure, such as for federal states. 
Operationalization:

Does a national
recommendation on physical activity and health exist in your country, i.e. an
officially adopted statement on the duration, intensity and frequency of
physical activity behaviour that the population should reach? 
Yes / no
If yes: 
Currently being developed
/ not foreseen for development in the next 2 years 
For adults / for young
people / for elderly people
Data sources and methods used
Information on
this indicator has been collected through a joint WHO/EC project on “Monitoring
progress on improving nutrition and physical activity and preventing obesity in
the European Union”. It is available in the European database on nutrition,
obesity and physical activity (NOPA), an internet-based information and
reporting system to describe and monitor progress diet, nutrition and physical
activity in the fight against obesity (see also chapter 3). 
Geographic and
temporal coverage
The project’s
“National Information Focal Persons” from 44 of the 53 WHO Member States
responsible to collate all necessary information from the relevant ministries
and institutions filled in reporting templates in 2009 and 2010. Information on
national recommendations was updated in 2011 and is available for about 40 of
53 Member States. 
Frequency of
update
An update of the
information collection for NOPA is foreseen for 2012/2013; further updates
depend on future funding.
References 
·                         
Global recommendations
on physical activity for health. Geneva, World Health Organization, 2010 (http://www.who.int/dietphysicalactivity/global-PA-recs-2010.pdf).

·                         
WHO European database
on nutrition, obesity and physical activity (NOPA). Copenhagen, WHO Regional
Office for Europe, 2010 (http://data.euro.who.int/nopa/default.aspx,
accessed 21 June 2012). 
2.4.2.     Indicator
2: Adults reaching the minimum WHO recommendation on physical activity for
health
What does this indicator tell us?
Reaching the
minimum recommendations is related to specific health benefits as identified by
extensive scientific research. Thus, the proportion of adults reaching these
recommendations illustrates the share of the adult population being
sufficiently physically active not to risk negative health consequences related
to insufficient physical activity.
Definitions and operationalization
The minimum WHO
recommendation on physical activity for health for adults is as follows: 
Adults should
do at least 150 minutes of moderate-intensity aerobic physical activity
throughout the week, or do at least 75 minutes of vigorous-intensity aerobic
physical activity throughout the week, or an equivalent combination of
moderate- and vigorous-intensity activity.
Operationalization:

Percentage of
adults reaching at least 150 minutes of moderate-intensity aerobic physical
activity throughout the week, or an equivalent of vigorous-intensity physical
activity, or a combination of moderate- and vigorous-intensity activity. 
Adults are often
defined as 18–64 years olds but age ranges can differ and may in some countries
also include the elderly. The minimum WHO recommendation for over 64-year olds
is the same as for adults (but additional elements are recommended). 
Data sources and methods used
Internationally
comparable data 
There are two
potential data sources of international data for this indicator: 1) The Global
Health Observatory of the WHO contains internationally comparable estimates on
this indicator; and 2) the European Health Interview Survey (EHIS). For the
second wave of EHIS (to be conducted in 2014) Commission Regulation 141/2013[13] was adopted and consequently these data
will have to be used for the monitoring framework. 
- Global Health Observatory
Description of
method used for comparable estimates (source see references): 
For comparable
estimates of insufficient physical activity, surveys were included that
presented sex- and age-specific prevalence with sample sizes (minimum: n=50),
using the definition of not meeting any of the following criteria: at least 30
minutes of moderate-intensity activity per day on at least 5 days per week, or
at least 20 minutes of vigorous-intensity activity per day on at least 3 days
per week, or an equivalent combination. Only surveys were included that
captured activity across all domains of life including work/household,
transport and leisure time. Data had to come from a random sample of the
general population, with clearly indicated survey methods.
In order to
report comparable data for a standard year (2008) and standard age groups,
adjustments were made for over-reporting of the International Physical Activity
Questionnaire (IPAQ) (1-3) coverage (urban and rural), and age coverage of the
survey. Using regression modelling techniques, crude adjusted prevalence values
were produced for 5-year age groups, and then combined for ages 15+ years,
using country population estimates. To further enable comparison among
countries, age-standardized comparable estimates were produced. This was done
by adjusting the crude estimates to an artificial population structure, the WHO
Standard Population, that closely reflects the age and sex structure of most
low and middle-income countries. This corrects for the differences in age and
sex structure between countries. Uncertainty in estimates was analysed by
taking into account sampling error and uncertainty due to statistical
modelling.
Data are presented
as crude and age-standardized estimates, by sex and as total. 
- European Health Interview Survey (EHIS)
The EHIS
instrument used in the first wave (2007/2010) was a questionnaire which was
based on the IPAQ (short version) to measure the proportion of populations
performing moderate and vigorous physical activity (days and/or hours per
week), derived from the following questions (PE.1-6): During the past 7 days,
a) days and time devoted to vigorous physical activities, b) days and time
devoted to moderate physical activities, c) days and time spent walking.
However, the EHIS wave 1 instrument used a different phrasing for the questions
on time spent in vigorous or moderate activities than in the original IPAQ.
Therefore, the exact measurement specifications for reliability, validity and
specificity of the EHIS wave 1 questionnaire are unknown. In addition data on
physical activity from the first wave of EHIS is only available for 12
countries. For EHIS wave 2 the variables and the questionnaire has been
revised. The resulting outcome indicators of the EHIS wave 2 instrument cover
three public-health-relevant domains of physical activity: (A) work-related
physical activity, (B) transportation (commuting) activity, and (C)
leisure-time physical activity. The new instrument is based on the framework of
the Global Physical Activity Questionnaire (GPAQ) using a modified version of
the current question from the Behaviour Risk Factor Surveillance System (BRFSS)
to assess work-related physical activity, the current NHIS-PAQ question to
assess muscle-strengthening physical activity and modified versions of the GPAQ
questions to assess transportation physical activity, and leisure-time physical
activity. In addition, it is designed to measure compliance with the new WHO
physical activity recommendations for the adult population aged 18-64. 
Data is foreseen
to be available by country, calendar year, sex, age groups (15-64, 65+, or
others) and socio-economic status (educational level, ISCED aggregated groups,
etc.). Eurostat can also calculate age-standardized EHIS data.
Information on national surveys
Information on
available national surveys in all EU countries on levels of physical activity
in adults has been collected through a joint WHO/Commission project on
“Monitoring progress on improving nutrition and physical activity and
preventing obesity in the European Union”. The information is included in the
European database on nutrition, obesity and physical activity (NOPA) and will
become available for the public before the summer 2013. An initial analysis
published in the summary has shown that data from national surveys are usually
not easily comparable across countries as they use different questionnaires and
methodologies. 
Geographic and temporal coverage
In the Global
Observatory, data for 2008 is presented for all EU countries as well as some
neighbouring countries, including Croatia, Iceland, Norway, Poland, Serbia, Switzerland and others). 
Data on physical
activity from the first wave of EHIS is available for 12 countries. The second
wave is foreseen for implementation in all EU countries following the 2013
Commission Regulation on EHIS. 
The national data
from the WHO/Commission project is available for all EU countries and is
covering largely varying time frames, as available on national level. 
Frequency of update
Updates of the
global observatory are foreseen to take place about every 2 to 3 years. 
The EHIS is
foreseen to be carried out every 5 years. MS are requested to provide micro
data for the reference year 2014 (or 2013 or 2015 for some countries) to be
made available at the latest by 30/9/2015 or 9 months after the end of the
national data collection period in cases where the survey is carried out beyond
12/2014.
An update of
information on national surveys is foreseen for 2012/2013; further updates
depend on future funding.
Comments 
With regard to the
vigorous-intensity part of the recommendations it has to be noted that the
global recommendations on physical activity for health recommend 75 minutes per
week. The Global Health Observatory of the WHO used the definition of at least
20 minutes of vigorous-intensity activity per day on at least 3 days per week.
Both definitions can be used by countries; the exact definition is to be
reported along with the data
EHIS (wave 1) used
the definition of percentage of the population practising at least 30 minutes
of physical activity (moderate or intense) per day. The second wave of EHIS was
adapted to include 8 basic variables on physical activity taking into account
WHO recommendations of 2011.[14]
References 
·                         
Global recommendations
on physical activity for health. Geneva, World Health Organization, 2010 (http://www.who.int/dietphysicalactivity/global-PA-recs-2010.pdf, accessed 20 April 2012). 
·                         
International Physical Activity
Questionnaire (IPAQ). The IPAQ
group (https://sites.google.com/site/theipaq/home, accessed 20 April 2012). 
·                         
Global Health
Observatory: Prevalence of insufficient physical activity [website]. Geneva, World Health Organization, 2012 (http://www.who.int/gho/ncd/risk_factors/physical_activity_text/en/index.html, accessed).
·                         
Global Health
Observatory Data Repository (see Noncommunicable diseases, risk factors,
physical inactivity) [website]. Geneva, World Health Organization, 2012 (http://apps.who.int/ghodata/, accessed 20 April 2012).
·                         
European Health
Interview Survey (EHIS wave 1) Questionnaire – English version. Brussels, European Commission EUROSTAT and Partnership on Public Health Statistics Group
HIS, 2006 (http://ec.europa.eu/health/ph_information/implement/wp/systems/docs/ev_20070315_ehis_en.pdf, accessed 1 November 2012). 
·                         
Commission Regulation
(EU) No 141/2013 of 19 February 2013 implementing Regulation (EC) No 1338/2008
of the European Parliament and of the Council on Community statistics on public
health and health and safety at work, as regards statistics based on the
European Health Interview Survey (EHIS);
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2013:047:0020:0048:EN:PDF
·                         
WHO European database
on nutrition, obesity and physical activity (NOPA). Copenhagen, WHO Regional
Office for Europe, 2010 (http://data.euro.who.int/nopa/default.aspx, accessed 21 June 2012). 
·                         
Report of the workshop
on integration of data on physical activity patterns. Zurich, Switzerland,
25–26 February 2009. WHO/Commission Project on monitoring progress on improving
nutrition and physical activity and preventing obesity in the European Union.
Report no. 4. Copenhagen, WHO Regional Office for Europe, 2010 (http://www.euro.who.int/__data/assets/pdf_file/0004/87430/E93705.pdf).

2.4.3.     Indicator
3: Children and adolescents reaching the minimum WHO recommendation on physical
activity for health
What does this indicator tell us?
Reaching the
minimum recommendations is related to specific health benefits as identified by
extensive scientific research. Thus, the proportion of children and adolescents
reaching these recommendations illustrates the share of the young population
being sufficiently physically active not to risk negative health consequences
related to insufficient physical activity.
Definitions and operationalization
The minimum WHO
recommendation on physical activity for health for children and adolescents is
as follows: 
Children and
youth should accumulate at least 60 minutes of moderate- to vigorous-intensity
physical activity daily.
Operationalization:

Percentage of
children and adolescents reaching at least 60 minutes of moderate- to
vigorous-intensity physical activity (MVPA) daily or on at least 5 days per
week (the 2005/2006 HBSC analysis - see Data sources below - used daily
activity as the cut-off point, the 2001/2002 used daily activity). 
As part of the WHO’s
European Environment and Health Information System (ENHIS), a fact sheet fact
sheet on “Percentage of physical active children and adolescents” was produced
for which a special analysis of the data from the 2001/2002 survey was
conducted using 60 minutes of MVPA on at least five days a week as cut-off
point to allow for comparison of the results with those obtained from the
2001/2002 survey.
Children and
adolescents have been defined as aged 5 to 17 years in the WHO Global
Recommendations on Physical Activity for Health but this can differ and the
exact age range used by countries is to be reported along with the data.
Data sources and methods used
The Health
Behaviour in School-Aged Children (HBSC) study collects data on this indicator
in 11, 13 and 15 year olds. It uses an internationally standardised
questionnaire that has been validated against objective measurements in a US
sample. To date, no internationally comparable data on younger children is
available, and due to different instruments used, national data are often not comparable.
Geographic and
temporal coverage
Twenty-five EU
countries participate in the study, as listed on the HBSC website (see
references below). Data on physical activity in youth was collected in
2001/2001, 2005/2006 and 2009/10. 
Frequency of
update
HBSC surveys are
carried out at four-year intervals.
References
·                         
The Health Behaviour in
School-Aged Children: WHO Collaborative Cross-National Study (HBSC) [website].
St Andrews, The University of St Andrews, 2002 (http://www.hbsc.org,
accessed 23 April 2012). 
·                         
A fact sheet fact sheet
on “Percentage of physically active children and adolescents”. WHO’s European
Environment and Health Information System (ENHIS). Copenhagen, WHO Regional
Office for Europe, 2009 (http://www.euro.who.int/__data/assets/pdf_file/
0012/96987/2.4.-Percentage-of-physically-active-children-EDITED_layoutedV2.pdf,
accessed 23 April 2012).
2.4.4.     Indicator
4: National coordination mechanism on HEPA promotion
What does this indicator tell us?
HEPA promotion
needs to take an intersectoral approach to be successful. Coordinated and
concerted action of all relevant sectors is crucial to avoid duplication or
contradictory action. The existence of a national coordination mechanism shows
that steps have been taken to promote concerted action across sectors. 
Definitions and operationalization
In order to ensure
coordinated action of all relevant government sectors and stakeholders, some
countries have installed a national coordination mechanism. Such a mechanism
can for example take the form of an informal working group, an advisory body or
a formal intersectoral government body. In order to be applicable for this
indicator, the body must have a clear mandate on the promotion of physical
activity, and not focus mainly on NCDs, obesity or other areas. 
Stakeholder: any
person, group or organisation who holds an important or influential community
position, and who might have an interest, investment or involvement in the
issue being investigated. Stakeholders include people in government and other
positions of power at a national, regional or city level; local policy makers
and service providers, people in the community where projects may be
introduced; and people who may benefit (or lose out in some way) from the
intervention
Operationalization: 
Has a specific
coordinating mechanism (e.g. working group, advisory body, coordinating
institution etc) been developed for HEPA promotion in your country?
Yes / no. 
If yes: 
What is the name of
the body? 
Since when is it in
place? 
Which stakeholders are
participating (pre-defined list)
Which is the leading institution?
Has funding been
allocated to this coordinating mechanism? 
If yes, how much
(in EUR)? 
1) total funding; 
2) funding per
capita; 
3) funding by
gross domestic product at PPP per capita. 
Data sources and methods used
Information on
this indicator has been collected in 2009 and 2010 for all items but
information on funding (which could be included in the future) through a joint
WHO/EC project on “Monitoring progress on improving nutrition and physical
activity and preventing obesity in the European Union”. It is available publicly
in the European database on nutrition, obesity and physical activity (NOPA). A
summary of the available information as at 2010 has been published. 
Geographic and
temporal coverage
The WHO/EC
project’s “National Information Focal Persons” responsible to collate all
necessary information from the relevant ministries and institutions filled in
reporting templates in 2009 and 2010. Information is available from 44 of the
53 WHO Member States, including all EU countries.
Frequency of
update
An update of the
information collected for NOPA is foreseen for 2012/2013; further updates
depend on the new structures to be set up as part of the proposed
Recommendation on HEPA and related funding.
References 
·                         
WHO European database
on nutrition, obesity and physical activity (NOPA). Copenhagen, WHO Regional
Office for Europe, 2010 (http://data.euro.who.int/nopa/default.aspx,
accessed 21 June 2012).
·                         
Review of physical
activity promotion policy development and legislation in European Union Member
States. WHO/EC Project on monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union. Report no. 10.
Copenhagen WHO Regional Office for Europe, 2010 (http://www.euro.who.int/__data/assets/pdf_file/
0015/146220/e95150.pdf, accessed 4 July 2012). 
2.4.5.     Indicator
5: Funding allocated specifically to HEPA promotion
What does this indicator tell us?
Financial
resources allocated specifically to HEPA promotion is a strong indicator of the
importance a country attaches to this topic within its policy agenda. Broken
down into the sources from which the funding comes from also gives an
indication on the 'intersectorality' of a country’s approach. 
Definitions and operationalization
HEPA promotion
includes all forms of physical activity that are beneficial for health without
undue harm or risk, i.e. health, sport, transport, environment or leisure time
approaches. 
Operationalization:

Yearly funding (in
Euros) allocated specifically to HEPA promotion. 
Sources from all
relevant sectors have to be included; it is preferable to report data by
sector, including if possible information on the development of funding over
the last 5 years if reported for the first time. In general, only national
funding from government sources should be included; in countries with a
decentralized and/or federal structure, sub-national funding can be included if
relevant. 
To correct for
country size and economic development, information has to be reported as: 1)
total funding; 2) funding per capita; 3) funding by gross domestic product at
purchasing power parity per capita. 
In cases where it
is not possible at the current stage to report quantitative information, the
state of funding can be described qualitatively, including if possible
information on the development of funding over the last 5 years if reported for
the first time. 
Data sources
Information on
this indicator has been collected in 7 countries within the framework of a
project of the HEPA Europe working group on “National approaches to physical
activity” on the HEPA Policy Audit Tool (PAT) – see above and chapter 3. The
PAT provides a protocol and method for a detailed compilation and communication
of country level policy responses on physical inactivity. 
In the future, the
information would need to be collected by questionnaire through the Expert
Group on “Sport, Health and Participation” (XG SHP). 
Geographic and
temporal coverage
So far,
information is available for 2010 for Finland, Italy, Norway, the Netherlands,
Portugal, Slovenia, and Switzerland from the HEPA PAT project.
The XG SHP is
supposed to cover all EU countries. 
Frequency of
update
An update of NOPA
is foreseen for 2012/2013; further updates depend on future funding. The Expert
Group monitoring frequency of update can be further defined, based on need and
feasibility.
References 
·                         
Gross domestic product
based on purchasing-power-parity (PPP) per capita GDP: 
World Economic Outlook Database. Washington,
International Monetary Fund, 2012 (http://www.imf.org/external/pubs/ft/weo/2012/01/weodata/index.aspx,
accessed 21 April 2012). 
World Development Indicators database, Washington, World Bank, 2012 (http://databank.worldbank.org/ddp/home.do?Step=12&id=4&CNO=2,
accessed 21 April 2012).
·                         
Bull FC, Milton K,
Kahlmeier S. Health-enhancing physical activity (HEPA) policy audit tool.
Copenhagen, WHO Regional Office for Europe, 2011 (www.euro.who.int/hepapat, accessed
21 April 2012). 
2.4.6.     Indicator 6: National Sport for All policy or action plan
What does this indicator tell us?
Sport promotion is
a crucial part of a comprehensive HEPA promotion strategy, provided that it
includes a strong focus on Sport for All approaches and does not mainly favour
elite sports. The development of a national Sport for All policy or action plan
illustrates such a focus. 
Definitions and operationalization
Sport for All:
refers to the systematic provision of opportunities for physical activity that
are accessible for everybody. 
Policy: written
document that contains strategies and priorities, define goals and objectives,
and is issued by a part of the administration. It may also include an action
plan on implementation. 
Action plan:
usually prepared according to a policy and strategic directions and should
ideally define who does what, when, how, for how much, and have a mechanism for
monitoring and evaluation. 
Operationalization: 
Does your country
have a national policy and/or a national action plan on Sport for All
promotion? Alternatively, is Sport for All addressed specifically in other
policy documents?
Yes / no. 
If yes, please
provide: name, year of publication, status (adopted, final version, draft
version), issuing body, policy areas covered, web link to the document. 
Data sources
Information on
this indicator has been collected in 2009 and 2010 through a joint WHO/EC
project on “Monitoring progress on improving nutrition and physical activity
and preventing obesity in the European Union”. Information on sport policies
has been complemented through the joint WHO/DG EAC project NET-SPORT-HEALTH
which analysed sport policies in the European region, with a focus on synergies
between sport and health policies. The data is available in the European
database on nutrition, obesity and physical activity (NOPA), an internet-based
information and reporting system to describe and monitor progress diet,
nutrition and physical activity in the fight against obesity (see also chapter
3). 
Geographic and
temporal coverage
The WHO/DG SANCO
project’s “National Information Focal Persons” responsible to collate all
necessary information from the relevant ministries and institutions filled in
reporting templates in 2009 and 2010. Information is available from 44 of the
53 WHO Member States, including all EU countries.
The
NET-SPORT-HEALTH project collected information in 2010, receiving replies from
20 of the 28 EU countries. 
Frequency of
update
An update of the
information collected for NOPA is foreseen for 2012/2013; further updates
depend on future funding.
References 
·                         
WHO European database
on nutrition, obesity and physical activity (NOPA). Copenhagen, WHO Regional
Office for Europe, 2010 (http://data.euro.who.int/nopa/default.aspx,
accessed 21 June 2012).
·                         
Promoting sport and
enhancing health in European Union countries: a policy content analysis to
support action. Copenhagen, WHO Regional Office for Europe, 2011 (http://www.euro.who.int/en/what-we-do/health-topics/disease-prevention/physical-activity/publications/2011/promoting-sport-and-enhancing-health-in-european-union-countries-a-policy-content-analysis-to-support-action,
accessed 7 July 2012). 
·                         
Christiansen N,
Kahlmeier S, Racioppi F: Sport promotion policies in the European Union:
results of a contents analysis. Scandinavian Journal of Medicine and Science in
Sports, in press. 
·                         
Review of physical
activity promotion policy development and legislation in European Union Member
States. WHO/EC Project on monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union. Report no. 10.
Copenhagen WHO Regional Office for Europe, 2010 (http://www.euro.who.int/__data/assets/pdf_file/0015/146220/e95150.pdf,
accessed 4 July 2012).
2.4.7.     Indicator
7: Sport Clubs for Health Programme 
What does this indicator tell us?
Sport promotion is
an important part of a comprehensive HEPA promotion strategy and sport clubs,
the backbone of the sport movement, can make an important contribution to
address low levels of physical activity in Europe. However, an analysis of
current approaches has shown that the link between sport and health promotion
can be further strengthened. The Sport Clubs for Health Programme has been
specifically designed to support Sport Clubs in providing programmes with a
stronger health promotion approach. 
Definitions and operationalization
Sport Club: the
basic local functional unit of many sport systems, usually voluntary civic-
organisations in which people engage in sport.
Sport Club for
Health (SCforH): an approach in which sport clubs are encouraged to invest into
health-related sport activities and /or health promotion within sport activities.
Health-oriented sport clubs recognises health in their activities. Health
promotion is not the main orientation, but has been recognised as one of the
main operating principles. 
Guidelines for
SCforH: a manual has been developed as part of a HEPA Europe/TAFISA working
group, supported by a grant of DG EAC as part of the "2009 Preparatory
action in the field of sport". 
Operationalization:

Are the Sport
Clubs for Health Guidelines implemented in sport clubs in your country? 
Yes / no
            If
yes: description of implementation activities (outline of number of sport clubs
that implement the programme, support provided from the national or
sub-national level for the implementation of the programme, existence of a
coordinator and if yes, contact information for further information). 
Data sources
Data on this
indicator is not yet being collected. The information could be collected by
questionnaire through the Expert Group on “Sport, Health and Participation” (XG
SHP).
Geographic and
temporal coverage
Data should be
collected from all EU countries by year. The XG SHP is supposed to cover all EU
countries.
Data should be
updated yearly. 
References 
·                         
Sport Clubs for Health
project. Helsinki, Finnish Sport for All Association, 2011 (http://www.kunto.fi/en/sports-club-for-health/,
accessed 7 July 2012). 
·                         
Kokko S, Oja P, Foster
C, Koski P, Laalo-Haikio E, Savola J (Eds.): Sports Club for Health –
Guidelines for health-oriented sports activities in a club setting. Nurmijarvi,
Finnish Sport for All Association, 2011 (http://www.kunto.fi/@Bin/463608/SCforH_Guidelines.pdf,
accessed 7 July 2012). 
·                         
Sport clubs for health
(http://www.euro.who.int/en/what-we-do/health-topics/disease-prevention/physical-activity/activities/sport-clubs-for-health,
accessed 7 July 2012). Copenhagen, WHO Regional Office for Europe. 
2.4.8.     Indicator
8: Framework to support offers to increase access to exercise facilities for
socially disadvantaged groups
What does this indicator tell us?
While low levels
of physical activity are widespread across Europe, they are particularly
prevalent in low socio-economic groups. This is of particular concern as often,
detrimental health behaviours are clustered within these groups, such as
unhealthy nutrition, inactivity and smoking. Thus, addressing such groups by
targeted approaches is crucial from a health, social and economic point of
view. Classic sport or health promotion approaches are often not sufficient to
reach such groups. Providing specific frameworks addressing low socio-economic
groups is therefore indicative of the recognition of this problem and the
willingness to invest into particular activities directed at such groups. 
Definitions and operationalization
Socially
disadvantaged groups: groups of the society which are disadvantaged with regard
to socio-economic aspects (income, socio-economic status, education or
employment), age and social determinants such as gender, ethnicity, culture or
religion. 
Framework to
support offers to increase access to recreational or exercise facilities: such
frameworks can take different forms, such as a specific national or
sub-national programme on this topic, incentive schemes to address such aspects
within existing facilities or the development of specifically designed offers. 
Recreational
facilities: include buildings or places that provide services aimed
specifically at spending leisure time outside of work or school or home duties.
This can include sport/exercise facilities, leisure time infrastructure and
urban and green spaces (e.g. gyms, public pools, parks, cycling paths, water
fronts, woods, play grounds, etc.). 
Exercise
facilities: include buildings or places that provide services aimed
specifically at being physically active to improve health or wellbeing. 
Operationalization:

Does a specific
framework exist to support offers to increase access to recreational or
exercise facilities for socially disadvantaged groups in your country? 
Yes / foreseen
within the next 2 years / no
If yes: please
describe the nature of the framework (name, year(s) of implementation,
expansion across the country, leading institution, funding).
Data sources
As part of the
joint WHO/EC project on “Monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union”, information
was collected on whether there was a specific focus on disadvantaged social or
socioeconomic groups in a list of 42 activities, programmes and strategies of
national governments addressing, amongst others, active transport, physical
activity and sport promotion and education in physical activity. Information on
the existence of a specific national or sub-national framework was not
specifically collected but is foreseen for the next data collection. The
information is not yet available in the European database on nutrition, obesity
and physical activity (NOPA), an internet-based information and reporting
system to describe and monitor progress diet, nutrition and physical activity
in the fight against obesity.
Geographic and
temporal coverage
The project’s
“National Information Focal Persons” responsible to collate all necessary
information from the relevant ministries and institutions filled in reporting
templates in 2009 and 2010. Information is available from 44 of the 53 WHO
Member States, including all EU countries.
Frequency of update
An update of the
information collection for NOPA is foreseen for 2012/2013; further updates
depend on future funding.
References 
·                         
Reporting template 1
(2009). WHO/EC Project on “Monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union”. Copenhagen,
WHO Regional Office for Europe, 2009. 
2.4.9.     Indicator
9: Target groups addressed by the national HEPA policy
What does this indicator tell us?
There are notable
differences in levels of physical activity and sport participation between
different socioeconomic and cultural subgroups of populations in European
countries. It is thus important to develop target-group specific activities as
part of an overall national HEPA promotion policy. Evidence of a specific focus
on different target groups is thus illustrative of the recognition of the need
to devise target-group specific action in order to achieve an overall increase
in physical activity levels. 
Definitions and operationalization
Policy: written
document that contains strategies and priorities, define goals and objectives,
and is issued by a part of the administration. It may also include an action
plan on implementation. 
HEPA promotion
policy: a policy aimed at increasing health-enhancing physical activity, i.e.
any type of a physical activity that is beneficial to one’s health bearing
minimum risks. It can include health, sport, transport or environmental
approaches.
Operationalization:

Which target
groups does / do the national or sub-national (where relevant, i.e. in
countries with a decentralized or federal structure) HEPA promotion
policy/policies address, especially regarding groups in particular need of
physical activity (e.g. low socio-economic groups, people with low levels of
physical activity, elderly people, ethnic minorities etc.)?
Data sources
As part of the
joint WHO/EC project on “Monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union”, information
was collected on all items of this indicator except for groups with low levels
of physical activity (which could be included in the future). The information
is available publicly in the European database on nutrition, obesity and
physical activity (NOPA) for each policy document except for groups with low
levels of physical activity. 
The project on “Improving Infrastructures for leisure-time physical
activity in the local arena” (IMPALA), which received support by the
Commission, developed guidelines on planning, building, financing, and managing
infrastructures for leisure-time physical activity with a special focus on
social equity. Aspects highlighted include an assessment of whether existing
infrastructure policies support social equity, the use of participatory
approaches in infrastructure planning, the consideration of social equity
issues in the design of new infrastructures, the use of financing mechanisms
that reduce entry barriers, and the use of facility management models that
improve access for socially disadvantaged groups. 
Geographic and temporal coverage
The WHO/EC
project’s “National Information Focal Persons” responsible to collate all
necessary information from the relevant ministries and institutions filled in
reporting templates in 2009 and 2010. Information is available from 44 of the
53 WHO Member States, including all EU countries.
IMPALA Project:
The guidelines were developed based on information collected in 11 EU countries
and Norway in 2009 and 2010.
Frequency of
update
An update of the
information collected for NOPA is foreseen for 2012/2013; further updates
depend on future funding.
References 
·                         
WHO European database
on nutrition, obesity and physical activity (NOPA). Copenhagen, WHO Regional
Office for Europe, 2010 (http://data.euro.who.int/nopa/default.aspx,
accessed 21 June 2012).
·                         
Proposed European
guidelines: Improving infrastructures for leisure-time physical activity in the
local arena. Towards social equity, intersectoral collaboration and
participation. Erlangen Nürnberg, Friedrich-Alexander-University of
Erlangen-Nuremberg and Institute of Sport Science and Sport, 2010 (www.impala-eu.org/fileadmin/user_upload/IMPALA_guideline_draft.pdf,
accessed 9 July 2012).
2.4.10.   Indicator
10: Monitoring and surveillance of physical activity
What does this indicator tell us?
Knowledge on the
levels and trends of physical activity over time are a crucial pre-requisite to
develop a comprehensive, targeted national strategy to increase physical
activity. Inclusion of physical activity into the national health monitoring
and surveillance system is an important indication of the recognition of its
importance as a health determinant and policy area. 
Definitions and operationalization
National health
monitoring and surveillance system: systematic collection, consolidation,
analysis and dissemination of data on the health status of the population for
use in public health action to reduce morbidity, mortality and to improve
health. 
Operationalization:

Does your country
have an established surveillance or health monitoring system that includes
population-based measures of physical activity? 
Yes / no. 
If
yes, please provide survey name and year(s), measured items (frequency,
duration, intensity, cycling/walking, sedentary behaviour), age groups and
socio-economic items covered, link to survey. 
Data sources
Information on
this indicator was collected as part of the joint WHO/EC project on “Monitoring
progress on improving nutrition and physical activity and preventing obesity in
the European Union”. The information is not yet available publicly through the
European database on nutrition, obesity and physical activity (NOPA) but is
foreseen for inclusion.
Geographic and temporal coverage
The WHO/EC
project’s “National Information Focal Persons” responsible to collate all
necessary information from the relevant ministries and institutions filled in
reporting templates in 2009 and 2010. Information is available from 44 of the
53 WHO Member States, including all EU countries.
Frequency of
update
An update of the
information collected for NOPA is foreseen for 2012/2013; further updates
depend on future funding.
References 
·                         
Reporting template 1
(2009). WHO/EC Project on “Monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union”. Copenhagen,
WHO Regional Office for Europe, 2009.
2.4.11.   Indicator
11: Counselling on physical activity
What does this indicator tell us?
Individualized
counselling on and prescription of physical activity can increase physical
activity levels. Thus, it can be suitable in an ordinary primary health care
setting to promote a more physically active lifestyle, in particular in target
groups that are otherwise difficult to reach. As it has been shown that it can
be difficult to encourage health care providers to include yet another topic
into their general counselling activities, financial incentives can be
provided. For example, physicians in primary health care can be financially
rewarded for encouraging patients to move more. Including counselling on
physical activity into, for example, schemes of insurance providers allows
defining and monitoring quality criteria related to the processes and outcomes
of counselling programmes.
Definitions and operationalization
Operationalization:

Does a programme
or scheme to promote counselling on physical activity exist in your country? 
Yes / no. 
If yes, is it
reimbursed as part of primary health care services, e.g. by insurance
companies? Please provide information on the programme or scheme to promote
counselling. 
Data sources
As part of the
joint WHO/EC project on “Monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union” information was
collected on this indicator, in particular whether such a scheme was a) not
existing, or not clearly stated in any policy document, and not planned within 2
years; b) clearly stated, partly implemented or enforced; or c) clearly stated
and entirely implemented and enforced. No information on reimbursement schemes
was collected but this could be included in the future. The information is not
yet available publicly in the European database on nutrition, obesity and
physical activity (NOPA) but foreseen for inclusion. 
Geographic and
temporal coverage
The WHO/EC's project’s
“National Information Focal Persons” responsible to collate all necessary
information from the relevant ministries and institutions filled in reporting
templates in 2009 and 2010. Information is available from 44 of the 53 WHO
Member States, including all EU countries.
Frequency of
update
An update of the
information collected for NOPA is foreseen for 2012/2013; further updates
depend on future funding.
References 
·                         
Reporting template 1
(2009). WHO/EC Project on “Monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union”. Copenhagen,
WHO Regional Office for Europe, 2009. 
2.4.12.   Indicator
12: Training on physical activity in curriculum for health professionals
What does this indicator tell us?
Health
professionals can play an important role in advocating for physical activity
and as facilitators between health insurance providers, their members or
clients, and providers of physical activity programmes. To fulfil this role,
they need to be appropriately trained on physical activity and health matters.
This indicator illustrates the degree to which this topic is addressed in their
curricula. 
Definitions and operationalization
Number of hours of
training in curriculum for health professionals (nurses, doctors) addressing
physical activity, and whether mandatory or optional
Operationalization:

(a)                   
Is physical activity
and health (health effects, determinants, effective interventions etc.) taught
in a module of the curriculum of medical doctors? 
Yes / no 
If yes: provide more information: 
·               
on the number of hours
of the respective module (or give a range of hours in case of different
sub-national programmes, or give a qualitative description)
·               
if the respective
course is mandatory or optional
·               
if there are clear
assessment and accreditation structures to reflect the learning outcomes on the
subject. 
(b)                   
Is physical activity
and health (health effects, determinants, effective interventions etc.) taught
in a module of the curriculum of nurses?
Yes / no 
If yes: provide more information: 
·               
on the number of hours
of the respective module (or give a range of hours in case of different
sub-national programmes, or give a qualitative description)
·               
if the respective
course is mandatory or optional
·               
if there are clear
assessment and accreditation structures to reflect the learning outcomes on the
subject. 
Data sources
Within the
framework of a joint WHO/EC project on “Monitoring progress on improving
nutrition and physical activity and preventing obesity in the European Union”,
some information on this indicator has been collected in 2009 and 2010. The
reporting template asked if “physical activity was included in the curriculum
of health professionals training” (programme not existing, or not clearly
stated in any policy document, and not planned within 2 years / clearly stated,
partly implemented or enforced / clearly stated and entirely implemented and
enforced). Further information as suggested above was not collected but is
foreseen to be included as a pilot-test into the next round of data collection.
The information is not yet available in the European database on nutrition,
obesity and physical activity (NOPA), an internet-based information and
reporting system to describe and monitor progress diet, nutrition and physical
activity in the fight against obesity but foreseen for publication. 
Geographic and
temporal coverage
The WHO/EC project’s
“National Information Focal Persons” responsible to collate all necessary
information from the relevant ministries and institutions filled in reporting
templates in 2009 and 2010. Information is available from 44 of the 53 WHO
Member States, including all EU countries.
Frequency of
update
An update of the
information collection for NOPA is foreseen for 2012/2013; further updates
depend on future funding.
References 
·                         
Reporting template 1
(2009). WHO/EC Project on “Monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union”. Copenhagen,
WHO Regional Office for Europe, 2009. 
2.4.13.   Indicator
13: Physical education in primary and secondary schools
What does this indicator tell us?
Schools are an
important setting to enhance physical activity of young people. School-based
physical education contributes to levels of physical activity and to improve
motor skills. In the last years, physical education lessons were reduced in
some countries due to economic or academic pressures. This indicator provides
an overview of amount of physical education provided at different age ranges. 
Definitions and operationalization
Operationalization:

(a)          What is
the number of hours of physical education provided in primary schools? 
·               
Are all of them or part
of them mandatory or optional? 
·               
Has this number of
hours changed over the last 3 years? 
·               
Please provide a
qualitative overview in case of sub-national regulations of physical education
at schools. 
(b)          What is
the number of hours of physical education provided in secondary schools? 
·               
Are all of them or part
of them mandatory or optional? 
·               
Has this number of
hours changed over the last 3 years? 
·               
Please provide a
qualitative overview in case of sub-national regulations of physical education
at schools. 
Data sources
The Eurydice Network provides information
on and analyses of European education systems and policies. Information on
physical education as a percentage of taught time has been included in key data
on education, which was published last in 2012. Absolute numbers of hours of
physical education taught in compulsory education are included in the annual
reports on taught time, last in 2012/2013. The absolute has also been covered
in the framework of a joint WHO/EC project on “Monitoring progress on improving
nutrition and physical activity and preventing obesity in the European Union”,
some information on this indicator has been collected in 2009 and 2010. The
reporting template asked on “mandatory inclusion of physical education in the
curriculum of primary and secondary school pupils” (not existing, or not
clearly stated in any policy document, and not planned within 2 years / clearly
stated, partly implemented or enforced / clearly stated and entirely implemented
and enforced). Further information as suggested above was not collected but is
foreseen to be pilot-tested in the next round of data collection. The
information is not yet available in the European database on nutrition, obesity
and physical activity (NOPA), an internet-based information and reporting
system to describe and monitor progress diet, nutrition and physical activity
in the fight against obesity but foreseen for publication. 
Geographic and
temporal coverage
As from 2013 the
Eurydice network consists of 40 national units
based in all 36 countries participating in the EU's Lifelong Learning programme
(EU Member States, EFTA countries, Croatia, the former Yugoslav Republic of
Macedonia, Montenegro, Serbia, and Turkey). It is co-ordinated and managed by
the EU Education, Audiovisual and Culture Executive Agency in Brussels, which
drafts its studies and provides a range of online resources.
The WHO/EC project’s
“National Information Focal Persons” responsible to collate all necessary
information from the relevant ministries and institutions filled in reporting
templates in 2009 and 2010. Information is available from 44 of the 53 WHO
Member States, including all EU countries.
Frequency of
update
Key data on
Education (including information on physical education) is published every
three years. Taught time diagrams are published annually.
An update of the
information collection for NOPA is foreseen for 2012/2013; further updates
depend on future funding.
References 
·                         
Reporting template 1
(2009). WHO/EC Project on “Monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union”. Copenhagen,
WHO Regional Office for Europe, 2009. 
2.4.14.   Indicator
14: Schemes for school-related physical activity promotion
What does this indicator tell us?
Schools are an
important setting to enhance physical activity of young people. While
school-based physical education is an important contribution, it is only
provided a few times per week and thus, additional school-related physical
activity offers are crucial to contribute to the recommended at least one hour
of daily physical activity for young people. This indicator gives an overview
of the provision of selected offers of school-related physical activity
promotion.
Definitions and operationalization
Active school
breaks: provision of offers and appropriate infrastructure to support young
people to include physical activity into their school breaks, including e.g.
walking paths around school ovals, adequate playground facilities or access to
equipment. 
Active breaks
during school lessons: structured brief activity sessions during school lessons
to break up longer sitting periods.
After-school HEPA
promotion programmes (at schools, at sport clubs or in communities): provision
of offers and appropriate infrastructure as well as access to community
infrastructure (e.g. bowling club, aquatic centre, cycling arena etc.) to
support young people to include physical activity into their after-school
programme. This can also include sports homework. 
Operationalization: 
Existence of a
national or sub-national (where relevant, i.e. in countries with a
decentralized or federal structure) scheme for: 
(a)                   
active school breaks
(b)                   
active breaks during
school lessons
(c)                   
after-school HEPA
promotion programmes (at schools, at sport clubs or in communities)
Yes / no
If yes, please
provide a brief description of the scheme(s) (lead institution, main contents,
funders, spread). 
Data sources
Data on this
indicator is not yet being collected. The information could be collected by
questionnaire through the Expert Group on “Sport, Health and Participation” (XG
SHP). Some information on 'Active school day measures' and 'Extracurricular
activities' is provided in the 2013 Eurydice report on Physical Education and
Sport at School in Europe (p. 19, 41, 45): http://eacea.ec.europa.eu/education/eurydice/documents/thematic_reports/150EN.pdf
Geographic and
temporal coverage
Data should be
collected from all EU countries by year. The XG SHP is supposed to cover all EU
countries.
Frequency of
update
Information on this indicator should be updated every
2 to 3 years. 
2.4.15.   Indicator
15: HEPA in training of physical education teachers
What does this indicator tell us?
Through the
provision of regular physical education (PE) classes, PE teachers play an
important role with regard to the promotion of physical activity and sport in
young people and as role models. It is thus important that they are fully
trained on the broader concept of HEPA, including all forms inside and outside
the sport arena and not only on classic sport approaches which are often not
adequate to reach those young people most in need of more activity. This
indicator illustrates to which degree the broader HEPA topic is addressed in
the training of PE teachers. 
Definitions and operationalization
HEPA promotion:
includes all forms of physical activity that are beneficial for health without
undue harm or risk, including sport, health, transport, environment or leisure
time approaches. 
Operationalization:

Is HEPA a module
in the training curriculum of PE teachers at bachelor's and/or master's degree
level? 
Yes / no 
If yes: is this
module mandatory or optional? 
Please provide a
qualitative overview in case of sub-national regulations on teacher training. 
Data sources
Within the
framework of a joint WHO/EC project on “Monitoring progress on improving
nutrition and physical activity and preventing obesity in the European Union”,
information on general teacher training to promote physical activity has been
collected in 2009 and 2010. Specific information on PE teacher training has not
been collected but is foreseen to be pilot-tested in the next round of data
collection. Some related information is provided in the 2013 Eurydice report on
Physical Education and Sport at School in Europe (chapter 5): http://eacea.ec.europa.eu/education/eurydice/documents/
thematic_reports/150EN.pdf
Geographic and
temporal coverage
The WHO/EC project’s
“National Information Focal Persons” responsible to collate all necessary information
from the relevant ministries and institutions filled in reporting templates in
2009 and 2010. Information is available from 44 of the 53 WHO Member States,
including all EU countries.
Frequency of update
An update of the
information collection for NOPA is foreseen for 2012/2013; further updates
depend on future funding.
References 
·                         
Reporting template 1
(2009). WHO/EC Project on “Monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union”. Copenhagen,
WHO Regional Office for Europe, 2009. 
2.4.16.   Indicator
16: Schemes promoting active travel to school
What does this indicator tell us?
Active transport,
i.e. walking, cycling, rollerblading, kick-boarding etc., is increasingly
recognised as an important possibility to increase overall physical activity.
It could be illustrated in different countries that young people who travel to
school in a physically active way are also overall more physically active. This
indicator informs on the existence of schemes to promote active school travel. 
Definitions and operationalization
Active travel: all
non-motorised forms of travel to school, walking, cycling, rollerblading,
kick-boarding etc. In most countries, the most prevalent forms will be walking
or cycling. 
Scheme to promote
active travel to school: such schemes can either consist of structured offers
such as “Safe Routes to School” or “Walking Bus” projects or can take the form
of a specific focus being put on the topic of active school travel in a
national transport or school policy. 
Operationalization:

Does a national or
sub-national (where relevant, i.e. in countries with a decentralized and/or
federal structure) scheme exist to promote active travel to school (e.g.
walking buses, cycling)?
Yes / no 
If yes, please
provide a brief description (national / sub-national, lead institution
government, schools, NGO etc., funding, spread) 
Data sources
Within the
framework of a joint WHO/EC project on “Monitoring progress on improving
nutrition and physical activity and preventing obesity in the European Union”,
some information on this indicator has been collected in 2009 and 2010. The
reporting template asked if there was a programme existing or planned
“promoting active travel (e.g. walking buses, cycling) for school children”. Further
information as suggested above would need to be retrieved from the additional
information, if provided, in the country information templates. The data is not
yet available in the European database on nutrition, obesity and physical activity
(NOPA), an internet-based information and reporting system to describe and
monitor progress diet, nutrition and physical activity in the fight against
obesity but foreseen for publication. 
Geographic and temporal coverage
The WHO/EC project’s
“National Information Focal Persons” responsible to collate all necessary
information from the relevant ministries and institutions filled in reporting
templates in 2009 and 2010. Information is available from 44 of the 53 WHO
Member States, including all EU countries. 
Frequency of
update
An update of the
information collection for NOPA is foreseen for 2012/2013; further updates
depend on future funding.
References 
·                         
Reporting template 1
(2009). WHO/EC Project on “Monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union”. Copenhagen,
WHO Regional Office for Europe, 2009. 
2.4.17.   Indicator
17: Level of cycling and walking
What does this indicator tell us?
Cycling and
walking are increasingly recognized as an important contribution to overall
physical activity, especially since these are forms of activity which are
accessible to almost everybody and which can be easily integrated into an
already busy day, e.g. during commuting, shopping or social activities, and
require minimal personal financial investments. The level of cycling and
walking thus illustrates the level of development of a country in this field
and can highlight potentials to increase investments into this area of physical
activity promotion. 
Definitions and operationalization
Data on the level
of cycling and walking: such data can be collected in different ways, including
through objective measurements (e.g. GPS-tracking), national travel surveys
using detailed individual travel diaries or as part of other national surveys.
From national travel surveys, data are usually collected as “kilometres
travelled (or time spent) cycling / walking per day for all travel purposes
(commuting, shopping, leisure, work)”. Alternatively, the level of cycling /
walking can also be defined as “main mode of transport used to get around on a
daily basis”. 
Operationalization:

As a recent
EU-funded study showed that currently, the availability of comparable data on
“kilometres travelled (or time spent) cycling / walking per day” is
insufficient (see Data sources below), it is suggested to operationalize this
indicator as follows:
What is the main
mode of transport that you use for your daily activities?
Car, motorbike,
public transport, walking, cycling, other, no daily / regular mobility.
As an alternative
EHIS wave 2 can offer data on walking and bicycling as its module on physical
activity foresees to measure time per day and number of days per week on
walking and bicycling. (see indicator 2 for references)
Data sources
A recent EC study
(led by DG MOVE) on “Harmonised collection of European data and statistics in
the field of urban transport and mobility" described existing projects
which have collected and harmonized data on urban mobility at European and/or
international scale and to collect information on the availability of, and
satisfaction with existing data and statistics at local level. For this
purpose, data from 64 cities in all 27 EU countries has been collected by
online survey and interview. The final project report was due by end of 2012.
Preliminary results show that many countries have carry out a national travel
survey. However, currently there are no standardized data on the level of
walking and cycling across all EU countries available from these surveys. In a
number of countries, walking and cycling are included in the national travel
surveys, while others still focus on motorized transport only. Sampling
frameworks and data collection methods are also not standardized. The study
underlines the need for European survey standards to accurately assess walking
as well as cycling. First attempts are underway, in particular through the
project “Measuring walking”, a joint project of the
European COST Action 358 “Pedestrian Quality Needs” and the WALK21
international conference series.
Information on
this indicator has also been collected for the first time in a Flash
Eurobarometer in 2011. 
Geographic and
temporal coverage
The Flash
Eurobarometer on “Future of transport” was carried out in 2011. Eurobarometer
surveys cover all 28 EU countries with a representative sample of about 1000
respondents aged 15 and older per country. Statistical results were weighted to
correct for known demographic discrepancies.
The above study
covers selected cities in all EU countries. 
Frequency of
update
Flash Eurobarometers
are usually not carried out on a regular basis. No information exists as to
when to repeat this survey in the future. 
Comments 
It should be borne
in mind that data from general surveys such as a Eurobarometer has some
weaknesses in comparison to data from national travel surveys. Travel surveys
are based on very detailed travel diaries where every bout of movement of a
certain length has to be recorded, in some cases starting as of 50 metres or
100 metres of length, depending on the methodology used. Respondents are well
instructed and accompanied during the survey, which is carried out over the
whole year to avoid a bias due to seasonality. Usually, the sample sizes of
such surveys are much larger than for normal phone surveys. This methodological
approach leads to more precise and reliable data. Also, the use of different
modes of transport throughout the survey day(s) is recorded, while in the
Eurobarometer survey, respondents had to decide on one mode of transport only.
Fieldwork was carried out during one month only (October 2011). In addition,
the Eurobarometer surveys might be more prone to underreporting non-motorized
modes of transport if they are not yet fully recognized as a standard means of
transport, which is still often the case for walking, and to some degree,
cycling, in some countries. 
For the future,
further standardized collection of travel survey data on countries' transport
systems, including collection of separate data on the amount of walking and of
cycling, should be encouraged.
References 
·                         
Flash Eurobarometer
Series no. 312: Future of transport. Analytical report. Survey requested by the
Directorate General Mobility and Transport. Brussels, European Commission, 2011
(http://ec.europa.eu/public_opinion/flash/fl_312_en.pdf,
accessed 4 July 2012). 
·                         
Study on “Harmonised
collection of European data and statistics in the field of urban transport and
mobility” (MOVE/B4/196-2/2010). University of Leuven, the Netherlands, on
behalf of DG for Mobility and Transport (MOVE). Final draft report_revision
July 2012. 
·                         
Measuring Walking:
Towards internationally standardised monitoring methods of walking and public
space (website). (http://www.measuring-walking.org/project/index.html,
accessed 21 August 2012). 
2.4.18.   Indicator
18: European Guidelines for improving Infrastructures for Leisure-Time Physical
Activity
What does this indicator tell us?
Leisure-time is an
important setting for physical activity, including but also extending beyond
classic sport activities. Availability and access for all population groups to
infrastructure for active leisure-time pursuits is a prerequisite for active
leisure time choices. European Guidelines have been developed to promote
comprehensive concepts to improve such infrastructure and this indicator will
inform on their diffusion and implementation. 
Definitions and operationalization
Infrastructures
for leisure-time physical activity: includes sport infrastructure, leisure-time
infrastructure and urban and green spaces;
Improvement of
infrastructures: includes development of appropriate policies as well as
aspects pertaining to planning, building, financing and management of
infrastructures;
European
Guidelines for improving Infrastructures for Leisure-Time Physical Activity:
these guidelines were developed with eleven EU Member States and Norway as part
of the EC-funded IMPALA project. They were presented in 2010 and include good
practice criteria and examples. 
Operationalization:

Are the “European
Guidelines for Improving Infrastructures for Leisure-Time Physical Activity”
applied systematically to develop leisure-time infrastructure? 
Yes / not yet but
foreseen within the next 2 years / no. 
Data sources
Information on
existing national mechanisms, policies and processes to plan infrastructure was
collected as part of the IMPALA project. Based on its project results, IMPALA
proposed “European Guidelines for Improving Infrastructures for Leisure-Time
Physical Activity in the Local Arena”. Aspects highlighted include the
involvement of relevant decision-making levels and policy sectors; the
application of appropriate and participatory planning procedures; the use of a
systematic assessment of existing infrastructures, physical activity behaviour,
and public needs; the development of accessible, ecological, safe, multi-use
infrastructures; the selection of appropriate and socially acceptable funding
mechanisms; and the choice of appropriate and flexible owner and operation
models. 
Information on the
future application of the guidelines in the 28 EU countries could be collected
by questionnaire through the Expert Group on “Sport, Health and Participation”.
Geographic and
temporal coverage
IMPALA: The
guidelines were developed based on information collected in 11 EU countries and
Norway in 2009 and 2010. 
Future data should
be collected from all EU countries by year. The Expert Group covers all EU
countries.
Frequency of
update
Information on this
indicator should be updated every 2 to 3 years. 
References 
·                         
Proposed European
guidelines: Improving infrastructures for leisure-time physical activity in the
local arena. Towards social equity, intersectoral collaboration and
participation. Erlangen Nürnberg, Friedrich-Alexander-University of
Erlangen-Nuremberg and Institute of Sport Science and Sport, 2010 (www.impala-eu.org/fileadmin/user_upload/
IMPALA_guideline_draft.pdf, accessed 9 July 2012). 
·                         
Engbers LH et al.:
Improving Leisure-time Physical Activity in the Local Arena (IMPALA): Report on
work package 1 (European comparison of national policies). Leiden, TNO Quality
of Life, 2010 (http://www.impala-eu.org/fileadmin/user_upload/
impala_report_wp1_policies.pdf, accessed 9 July 2012).
2.4.19.   Indicator
19: Schemes to promote active travel to work
What does this indicator tell us?
Active transport,
i.e. walking, cycling, rollerblading, kick-boarding etc., is increasingly
recognised as an important possibility to increase overall physical activity.
It has been shown in different countries that adults who commute to work in a
physically active way are also overall more physically active and, for example,
less overweight. This indicator informs on the existence of schemes to promote
active travel to work. 
Definitions and operationalization
Active travel: all
non-motorised forms of travel to school, walking, cycling, rollerblading,
kick-boarding etc. In most countries, the most prevalent forms will be walking
or cycling. 
Schemes to promote
active travel to work: such schemes can either be directed at employers, e.g.
in the form of a requirement to develop mobility plans above a certain number
of employees, a financial incentive schemes or of an NGO-lead programme, or can
provide incentives or subsidies to employees who use active forms of commuting.

Operationalization:

Does a national or
sub-national (where relevant, i.e. in countries with a decentralized and/or
federal structure) scheme exist to promote active travel to work (e.g. walking,
cycling)?
Yes / no 
If yes, please
provide a brief description (national / sub-national, lead institution -
government, NGO etc. -, contents, funding, spread) 
Data sources
Within the
framework of a joint WHO/EC project on “Monitoring progress on improving
nutrition and physical activity and preventing obesity in the European Union”,
some information on this indicator has been collected in 2009 and 2010. The
reporting template asked if there was a programme existing or planned
“promoting active travel (walking or cycling) to work”. Further information as
suggested above would need to be retrieved from the additional information, if
provided, in the country information templates. The data is not yet available
in the European database on nutrition, obesity and physical activity (NOPA), an
internet-based information and reporting system to describe and monitor
progress diet, nutrition and physical activity in the fight against obesity but
foreseen for publication. 
Geographic and
temporal coverage
The project’s
“National Information Focal Persons” responsible to collate all necessary information
from the relevant ministries and institutions filled in reporting templates in
2009 and 2010. Information is available from 44 of the 53 WHO Member States,
including all EU countries. 
Frequency of
update
An update of the
information collection for NOPA is foreseen for 2012/2013; further updates
depend on future funding.
References 
·                         
Reporting template 1
(2009). WHO/EC Project on “Monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union”. Copenhagen,
WHO Regional Office for Europe, 2009. 
2.4.20.   Indicator
20: Schemes to promote physical activity at the work place 
What does this indicator tell us?
The work place is
increasingly recognised as a setting where physical activity can be promoted.
Provided that provisions are taken to reach all groups of employees, work
place-related physical activity promotion can contribute to increasing levels
of physical activity. This indicator informs on the existence of schemes to
promote physical activity at the work place.
Definitions and operationalization
Schemes to promote
physical activity at work: such schemes can include structured offers, e.g.
sport programmes or walking classes during lunch time, provision of
infrastructure (gym, showers, walking tracks etc.), systematic consideration of
the topic in all work processes (stand-up desks, walking meetings etc.), or
incentives or subsidies for employees who use specific offers. In this setting
is has shown to be important to take provisions to reach all groups of employees
and not, for example, mostly those who are already physically active. 
Operationalization:

Does a national or
sub-national (where relevant, i.e. in countries with a decentralised and/or
federal structure) scheme exist to promote physical activity at work places? 
Yes / no
If yes, please
provide a brief description (national / sub-national scheme, lead institution -
government, NGO etc. - , contents, funding, spread)
Data sources
Within the
framework of a joint WHO/EC project on “Monitoring progress on improving
nutrition and physical activity and preventing obesity in the European Union”,
some information on this indicator has been collected in 2009 and 2010. The
reporting template asked if there was a programme existing or planned
“providing facilities for physical activity at the work place (e.g. gym,
basketball court, field etc.)”. Further information as suggested above is not
being collected and feasibility would need to be assessed in the next round of
data collection. The data is not yet available in the European database on
nutrition, obesity and physical activity (NOPA), an internet-based information
and reporting system to describe and monitor progress diet, nutrition and
physical activity in the fight against obesity (see also Annex) but foreseen
for publication. 
Exchange should
also be sought with the WHO’s Global Plan of Action on Workers’ health
2008-2014 which includes the promotion of physical activity at the workplace
and is foreseeing a monitoring framework on its implementation. 
Geographic and
temporal coverage
The WHO/EC project’s
“National Information Focal Persons” responsible to collate all necessary
information from the relevant ministries and institutions filled in reporting
templates in 2009 and 2010. Information is available from 44 of the 53 WHO
Member States, including all EU countries.
Frequency of
update
An update of the
information collection for NOPA is foreseen for 2012/2013; further updates
depend on future funding.
References 
·                         
Reporting template 1
(2009). WHO/EC Project on “Monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union”. Copenhagen,
WHO Regional Office for Europe, 2009. 
·                         
Occupational health
[website] (including link to Global Plan of Action on Workers’ health
2008-2014). Geneva, World Health Organization, 2012. 
2.4.21.   Indicator
21: Schemes for community interventions to promote PA in elderly people
What does this indicator tell us?
Remaining
physically active is of particular importance for older adults to maintain
mental and functional capacity and independence and to prevent falls. In view
of the ageing of most European societies, this topic will be of increasing
importance. This indicator will highlight the existence of specific schemes for
community interventions to promote physical activity in this age group. 
Definitions and operationalization
Scheme for
community interventions to promote PA in elderly people: such schemes can take
different forms, such as government-run programmes with specific offers for
elderly, investment in suitable leisure-time infrastructure or to increase
access to existing infrastructures (including transport infrastructures),
NGO-run projects and programmes in the general community or directed at
specific settings, such as nursing homes. 
Operationalization:

Existence of a
specific scheme or programme for community interventions to promote PA in
elderly people
Data sources
An initial
collection of good practices of physical activity programmes and physical
activity promotion strategies for older people was compiled as part of the EC-supported
project "European Network for Action on Ageing and Physical Activity"
(EUNAAPA) in 2007/2008 in 14 EU Member States and Norway. The information
collected included an overview of programmes and strategies deemed “successful”
by national-level experts and policy-makers, and an overview of existing
recommendations for the design of such programmes and strategies. 
Future information
could possibly come from one of the EC-funded projects on "European
Partnerships on Sport" (promoting physical activity supporting active
ageing) that started in 2013. Otherwise, information could be collected by
questionnaire through the Expert Group on “Sport, Health and Participation”.
Geographic and
temporal coverage
EUNAAPA: Data were
collected in 14 EU Member States and Norway in 2007 and 2008. 
Future data should
be collected from all EU countries. The Expert Group is supposed to cover all
EU countries.
Frequency of
update
Information on
this indicator should be updated every 2 to 3 years. 
References 
·                         
Scott F et al. Expert
survey on physical activity programmes and physical activity promotion
strategies for older people. Cross-national report. EUNAAPA – Work Package 5,
2008 (http://www.eunaapa.org/media/cross-national_report_expert_survey_on_pa_programmes_
and_promotion_strategies_2008_.pdf, accessed 9 July 2012)
2.4.22.   Indicator
22: National HEPA policies that include a plan for evaluation
What does this indicator tell us?
National policies
are a centre-piece of a national strategy to promote physical activity. The
will give support, coherence and visibility at the political level, and at the
same time make it possible for the institutions involved, such as national
government sectors, regions or local authorities, stakeholders and the private
sector, to be coherent and consistent by following common objectives and strategies
as well as to assign roles and responsibilities. Recent analyses have shown
that evaluation is not yet a sufficiently strong element in many national
policies. Evaluation is crucial for accountability and to support adaptation of
implementation to address weaknesses and improve effectiveness. This indicator
will provide an overview of the existence of national policies and which of
those have a clear commitment and plan for evaluation included. 
Definitions and operationalization
Policy: written
document that contains strategies and priorities, define goals and objectives,
and is issued by a part of the administration. It may also include an action
plan on implementation. 
Action Plan:
usually prepared according to a policy and strategic directions and should ideally
define who does what, when, how, for how much, and have a mechanism for
monitoring and evaluation.
HEPA promotion:
includes all forms of physical activity that are beneficial for health without
undue harm or risk, including sport, health, transport, environment or leisure
time approaches.
Operationalization:

Share of national
or sub-national (where relevant, i.e. in countries with a decentralized or
federal structure) HEPA policies (sport, health, transport, environment) that
include a clear intention or plan for evaluation;
X out of y
policies (by sector) include a clear intention or plan for evaluation
(alternatively: all / many / some / few / none[15]);
Data sources
Information on
this indicator has been collected in 2009 and 2010 through a joint WHO/EC
project on “Monitoring progress on improving nutrition and physical activity
and preventing obesity in the European Union”. The policy documents are
available in the European database on nutrition, obesity and physical activity
(NOPA), an internet-based information and reporting system to describe and
monitor progress diet, nutrition and physical activity in the fight against
obesity. The information provided also includes whether a monitoring and
evaluation plan for the policy document exists. 
Geographic,
topical and temporal coverage
The WHO/DG SANCO
project’s “National Information Focal Persons” responsible to collate all
necessary information from the relevant ministries and institutions filled in
reporting templates in 2009 and 2010. Information is available from 44 of the
53 WHO Member States, including all EU countries.
An earlier
complementary collection of sport-related policies (see also indicator 8:
National Sport for All policy or action plan) identified more than 100
additional policy documents, showing that it is likely that the currently
available information in NOPA is more complete for directly health-related
information than for other sectors. For a more complete coverage in particular
of transport and environment policies relating to physical activity, targeted
information collection projects would be advisable, based for example on the
approach taken in the NET-SPORT-HEALTH project. 
Frequency of
update
An update of the
information collected for NOPA is foreseen for 2012/2013; further updates
depend on future funding.
References 
·                         
WHO European database
on nutrition, obesity and physical activity (NOPA). Copenhagen, WHO Regional
Office for Europe, 2010 (http://data.euro.who.int/nopa/default.aspx,
accessed 21 June 2012).
2.4.23.   Indicator
23: National awareness raising campaign on physical activity
What does this indicator tell us?
A national
awareness raising campaign is a frequent element of national strategies to
promote physical activity. It can contribute to the dissemination of knowledge
and change of attitudes and, if complemented by specific offers, support a
behaviour change. This indicator will inform on the existence of such campaigns.

Definitions and operationalization
Awareness-raising
campaign: a mass media based approach to inform a community's attitudes,
behaviours and beliefs
Operationalization:

Does a clearly
formulated, national campaign for physical activity education and public
awareness raising exist?
Yes / no
            If yes, please specify: name
and link to web site, topics covered, responsible body, yearly budget in Euros.
To correct for
country size and economic development, information has to be reported as: 1)
total funding; 2) funding per capita; 3) funding by gross domestic product at
purchasing power parity per capita. 
Data sources
Information on
this indicator has been collected in 2009 and 2010 through a joint WHO/EC
project on “Monitoring progress on improving nutrition and physical activity
and preventing obesity in the European Union”, except for correcting the
funding information for country size and economic development. The information
is not yet available in the European database on nutrition, obesity and physical
activity (NOPA), an internet-based information and reporting system to describe
and monitor progress diet, nutrition and physical activity in the fight against
obesity but foreseen for publication. 
Geographic and
temporal coverage
The WHO/EC project’s
“National Information Focal Persons” responsible to collate all necessary
information from the relevant ministries and institutions filled in reporting
templates in 2009 and 2010. Information is available from 44 of the 53 WHO
Member States, including all EU countries.
Frequency of update
An update of the
information collected for NOPA is foreseen for 2012/2013; further updates
depend on future funding.
References
·                         
Reporting template 1
(2009). WHO/EC Project on “Monitoring progress on improving nutrition and physical
activity and preventing obesity in the European Union”. Copenhagen, WHO
Regional Office for Europe, 2009. 
3.           Key
information sources
·                        
European database on nutrition, obesity and
physical activity (NOPA)
The most comprehensive overview on HEPA policy-relates
aspects is now available from the joint WHO/EC project on “Monitoring progress
on improving nutrition and physical activity and preventing obesity in the
European Union”, which was carried out from 2008 to 2010. Its main goal was to
develop a European database on nutrition, obesity and
physical activity (NOPA), an internet-based information
and reporting system to describe and monitor progress diet, nutrition and
physical activity in the fight against obesity. The system aims at assisting
the EU and Member States in monitoring action to implement policies with regard
to key commitments contained in the three main policy documents: the European
Charter on Counteracting Obesity, the EC White Paper “A strategy for Europe on
nutrition, overweight and obesity related health issues” and the WHO European
Action Plan for Food and Nutrition Policy 2007–2012. 
It compiles information for most of the 53 WHO
European Member States from different available sources as well as reporting
templates filled in by the project’s “National Information Focal Persons”
responsible to collate all necessary information from the relevant ministries
and institutions; 44 of 53 Member States provided information which was (and on
some items currently still is being) verified before inclusion into the
database. The database contains information on all EU Member States. 
The chart hereafter gives an overview of NOPA. It
illustrates that NOPA contains a range of process and outcome related
information (e.g. national coordination, national policy documents national
physical activity recommendations). In addition, action on different community
interventions is included[16]
(not existing and not planned within 2 years, clearly stated, partly
implemented or enforced, clearly stated and entirely implemented and enforced,
or not yet existing, but planned within the next 2 years).
While NOPA contains a unique range of documents
and information on physical activity, a project to analyse the state of affairs
regarding physical activity recommendations showed that the database needs
continuous updating to preserve its high value as information repository, as
most of the information was collected in 2009 and 2010. The specific scope and
frequency of updating NOPA has been up until now negotiated between WHO and the
EC (DG SANCO). In some cases, the National Information Focal Persons might have
had better access to nutrition-related information than to data and documents
on physical activity, especially on aspects outside the health sector. This
fact will be addressed by the proposed Council Recommendation that foresees the
establishment of HEPA focal points.
European database on nutrition, obesity
and physical activity (NOPA)
From: Wijnhoven T, Bollars C, Racioppi R: WHO European
Database on Nutrition, Obesity and Physical Activity (NOPA). Presentation at
the 2nd Meeting of the HEPA Europe-EU Contact Group, Amsterdam, 12
October 2011.
·                        
Overviews and content analyses of national
policies 
Internationally, one of the first analyses of
selected national polices was published in 2004[17]. 
For Europe, Daugbjerg et al.[18] published the state of affairs as of April
2007, based on the International Inventory of Physical Activity Promotion. 54
national HEPA policy documents from 24 countries had been identified, of which
27 documents published in English were included in a systematic content
analysis. Studied elements were publication date, legal status, target groups,
implementation mechanisms, budget and evaluation and surveillance. Analysis
showed that many general recommendations for policy developments were being
followed. However, limited evidence for cross-sectoral collaboration was found
and quantified goals for physical activity were the exception. Population
groups most in need were rarely specifically targeted. Only about half of the
policies indicated an intention or requirement for evaluation. While this study
provided for the first time an overview on the state of affairs regarding HEPA
promotion in Europe and provided important findings, the content analysis only
analysed information as provided in the written policy documents. 
The overview of HEPA policy documents has been
updated for the EU Member States recently[19].

With regard to sport policies, the joint WHO/EC
(EAC) project NET-SPORT-HEALTH reviewed sport policies in the European region,
with a focus on synergies between sport and health policies[20]. 72% of the analysed documents
(and about 80% of all identified national policies) had been published before
2009 and therefore could not have been developed to reflect the recommendations
in the EU PA GL. This aspect was also part of the content analysis of 25
selected policy documents, where international policy frameworks that the
national strategies referred to were identified. In the 25 analysed documents,
the EU PA GL were not mentioned as a basis. However, only a sub-set of
documents was analysed and not mentioning them specifically does not
necessarily mean that the EU PA GL were not considered in the development of a
policy document.
·                        
WHO Global InfoBase and Global Health Data
Observatory
Since the adoption of the Global Strategy on
Diet, Physical Activity and Health in 2004, the WHO has undertaken activities
to collect information on the prevalence of NCDs as well as important risk
factors, including insufficient physical activity. Global surveillance data is
available in the WHO Global InfoBase. However, inter-country comparisons of
national data on physical activity from most European countries is difficult
since most of them use nationally-developed questionnaires that are not
comparable; in addition methodological challenges around the Eurobarometer
surveys have been mentioned elsewhere[21]. 
·                        
HEPA Policy Audit Tool
Based on previous analyses and international
guidance on the development of national approaches, work by the HEPA Europe
working group on “National approaches to physical activity” led to the HEPA
Policy Audit Tool (PAT)[22].
It provides a protocol and method for a detailed compilation and communication
of country level policy responses on physical inactivity. It is structured
around a set of 17 key attributes identified as essential for successful
implementation of a population-wide approach to the promotion of physical
activity across the life course, using the experience of several previous international
comparative studies of physical activity policy:
(1)         
Consultative approach in development
(2)         
Evidence based
(3)         
Integration across other sectors and policies
(4)         
National recommendations on physical activity
levels
(5)         
National goals and targets
(6)         
Implementation plan with a specified timeframe
for implementation
(7)         
Multiple strategies
(8)         
Evaluation
(9)         
Surveillance or health monitoring systems
(10)     
Political commitment
(11)     
On-going funding
(12)     
Leadership and coordination
(13)     
Working in partnership
(14)     
Links between policy and practice
(15)     
Communication strategy
(16)     
Identity (branding/logo/slogan)
(17)     
Network supporting
professionals
Completion of the HEPA PAT provides a
comprehensive overview of the breadth of current policies related to HEPA and
can identify synergies and discrepancies between policy documents as well as
possible gaps. It does not, however, provide a quantified assessment or scoring
of a national HEPA policy approach. 
The HEPA PAT has been applied in 7 pilot
countries (Finland, Italy, the Netherlands, Norway, Portugal, Slovenia, and Switzerland); a cross-country analysis is currently underway. Further updates are
foreseen. 
[1]               COM(2011) 12 final., 18.1.2011
[2]               http://ec.europa.eu/sport/library/documents/c1/eu-physical-activity-guidelines-2008_en.pdf
[3]               The consultation process for the initiative has been
described in detail in the Annex to the Impact Assessment accompanying the
proposal.
[4]               The Lancet, Volume 380, Issue 9838,
Pages 294 - 305, 21 July 2012
[5]               http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/educ/133870.pdf
[6]               Rossi P, Lipsey MW, Freeman H (2004):
Evaluation: a systematic approach. 7th ed., Newbury Park, California: Sage
Publications. 
Nutbeam D, Bauman A (2006): Evaluation in a Nutshell.
Australia: Mc-Graw Hill.
[7]               Aspects
of possible impacts of the EU PA GL have already been addressed in the Impact
assessment accompanying the Commission’s proposal and will therefore be less of
a focus here; however, some discussed indicators might relate to impacts as
well, and there will be iterations and cross-fertilisation across the two tasks
in this regard. 
[8]               Based
on: Government Assessment Portal: What makes a "good" governance
indicator? (http://www.gaportal.org/how-to/define-and-select-indicators/what-makes-good-governance-indicator) 
[9]               This approach was the basis for the preferred policy
option (Option C) in the Impact assessment accompanying the Commission’s
proposal.
[10]             The Commission would like to express sincere
appreciation to the national and international experts that helped in the
preparatory process to develop the monitoring framework and colleagues in the
Commission (DG EAC, DG MOVE, DG SANCO). We thank in particular, Dr. Sonja
KAHLMEIER (University of Zurich), Prof. Willem van MECHELEN (VU University
Medical Center), Prof. Finn BERGGREN (Gerlev Physical Education and Sports
Academy), Dr. Janine STUBBE (TNO), Prof. Dr. Roland NAUL (University of
Duisburg-Essen), Ioanna PARASKEVOPOULOU (Cyprus Sport Organisation), Dr. Alfred
RÜTTEN (University of Erlangen), Trudy WIJNHOVEN and Christian SCHWEIZER (WHO
Regional Office for Europe), Dr. Radim ŠLACHTA (Palacky University), Prof. Dr.
Therese STEENBERGHEN (University of Leuven), Martin KUEHNEMUND and Bradford
ROHMER (The Evaluation Partnership). We wish to extend our special thanks to
the members of the HEPA EUROPE EU CONTACT GROUP, the Expert Group "Sport,
Health and Participation" and the High-level Group on Nutrition and
Physical Activity for their support and contribution.
[11]             General approach to develop a monitoring framework presented
but not the detailed list of indicators. 
[12]             Participants:
Prof. Finn BERGGREN (Gerlev Physical Education and Sports Academy), Alberto S.
BICHI and Jerome Pero (Federation of the European Sporting Goods Industry),
Charlotte BOETTICHER (European Olympic Committees’ EU Office), Romana
CAPUT-JOGUNICA and Heidi PEKKOLA (European Non-Governmental Sports
Organisation), Cliff COLLINS (European Health and Fitness Association), Eric DE
BOEVER (European Physical Education Association), Guy DE GRAUWE (European Federation
for Company Sports), Aurélien FAVRE (European Observatoire of Sport and
Employment), Benjamin FOLKMANN (Deutsche Sportjugend im Deutschen Olympischen
Sportbund e.V.), Jorg FRANK (Council of European Municipalities and Regions),
Dr. Borja GARCÍA GARCÍA (Loughborough University), Dr. Paul KELLY (Oxford
University), Lena KNORR (Sports Department Stuttgart), Eerika LAALO-HÄIKIÖ (The
Association For International Sport for All), Dr. Brian MARTIN (University of
Zurich), Nicos MEGALEMOS (International School Sport Federation), Deborah NASH
(EU Sports Platform), Prof. Dr. Roland NAUL (University of Duisburg-Essen),
Ioanna PARASKEVOPOULOU (Cyprus Sport Organisation), Dr. Karen PETRY (European
Network of Sport Science, Education and Employment), Bradford ROHMER (The
Evaluation Partnership), Dr. Alfred RÜTTEN (University of Erlangen-Nürnberg),
Christian SCHWEIZER (WHO Regional Office for Europe), Jacob SCHOUENBORG
(International Sport and Culture Association), Herman SMULDERS (European
Confederation of Outdoor Employers), Stefan SZYMANSKI (European Sport Economics
Association), Jean-François TOUSSAINT EU (chair of Expert Group "Sport,
Health and Participation"), Prof. Willem van MECHELEN (VU University
Medical Center).
[13]             Commission Regulation 141/2013 of 19 February 2013 on
EHIS: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2013:047:0020:0048:EN:PDF.
A derogation for the Netherlands was granted for the physical activity
variables.
[14]             http://www.who.int/dietphysicalactivity/factsheet_adults/en/index.html
[15]             A
percentage would be prone to misinterpretation here: For example, if a country
just has one policy that includes evaluation they would get 100% but a country with
a comprehensive range of policies but only 8 out of 10 policies have evaluation
built-in would only get 80%. 
[16]             With
regard to PA, these include: promotion of physical activity in schools,
physical education in primary and secondary schools, promoting active travel
(e.g. walking buses, cycling) to school or work, teacher training to promote
physical activity, provision of facilities for physical activity at work
places, government subsidy scheme for companies to support active travel, programmes
to increase traffic safety for pedestrians and cyclists, expansion of
pedestrian zones (car-free zones) in cities, expansion of green spaces and play
areas in urban areas and of cycle and walking lanes, provision of sport
facilities and equipment to schools stated in national school policies, offers
to increase access to recreational or exercise facilities (e.g. subsidy
schemes), promotion of better urban design to provide safe and attractive
structures everyday physical activity, cycling and walking, e.g. through
Healthy Urban Planning, promoting stair use at workplace, physical activity
counselling in primary health care, physical activity included in the
curriculum of health professionals training. 
[17]             Bull
FC, Bellew B, Schoppe S, Bauman AE. (2004) Developments in national physical
activity policy: an international review and recommendations towards better
practice. Journal of Science and Medicine in Sport, Physical Activity Suppl,
7(1), 93-104.
[18]             Daugbjerg
SB, Kahlmeier S, Racioppi F et al. (2009): Promotion of physical activity in
the European region: content analysis of 27 national policy documents. Journal of Physical Activity
and Health, 6, 805-817. 
[19]             As of
2009, almost 140 national policies or legislative documents were identified
from 26 Member States. Seventy-three documents from 24 countries took a public
health approach to HEPA promotion, 34 documents from 16 countries had a sport
focus and 22 documents from ten countries were on transport approaches, while
environmental approaches were even more rarely identified. To a certain extent,
this might be a problem of underreporting non-health related documents
                (http://www.euro.who.int/__data/assets/pdf_file/0015/146220/e95150.pdf).
[20]             http://www.euro.who.int/__data/assets/pdf_file/0006/147237/e95168.pdf 
[21]             WHO Regional Office for Europe (2010):
Review of physical activity surveillance data sources in European Union Member
States. WHO/EC Project on monitoring progress on improving nutrition and
physical activity and preventing obesity in the European Union. Report no. 6. Copenhagen, WHO Regional
Office for Europe (http://www.euro.who.int/__data/assets/pdf_file/0005/148784/e95584.pdf). 
[22]             http://www.euro.who.int/hepapat