COMMISSION STAFF WORKING DOCUMENT IMPACT ASSESSMENT Accompanying the document Proposal for a Council Recommendation on promoting health-enhancing physical activity across sectors
Date: 2013-08-28
Institutions: European Commission
Subjects: European cooperation, World Health Organisation, cardiovascular disease, economic consequence, health care, impact study, nutritional disease, public awareness campaign, social impact, sport













EUR-Lex - 52013SC0311 - EN











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52013SC0311

COMMISSION STAFF WORKING DOCUMENT IMPACT ASSESSMENT Accompanying the document Proposal for a Council Recommendation on promoting health-enhancing physical activity across sectors /* SWD/2013/0311 final */









TABLE OF CONTENTS
1........... PROCEDURAL ISSUES AND
CONSULTATIONS................................................ 7
1.1........ Identification................................................................................................................... 7
1.2........ Organisation and Timing.................................................................................................. 7
1.3........ Impact Assessment Board (IAB).................................................................................... 7
1.4........ Consultations.................................................................................................................. 7
1.5........ Use of external expertise................................................................................................. 8
2........... PROBLEM DEFINITION......................................................................................... 9
2.1........ Context.......................................................................................................................... 9
2.1.1..... The importance of physical
activity.................................................................................. 9
2.1.2..... Policy context................................................................................................................. 9
2.2........ Identification and analysis of
the main problem(s)........................................................... 12
2.2.1..... Approach to HEPA not sufficiently
cross-sectoral......................................................... 14
2.2.2..... Objectives and goals not concrete
and clear enough...................................................... 16
2.2.3..... Insufficient provisions for
monitoring and evaluation....................................................... 17
2.3........ Underlying reasons for the main
shortcomings................................................................ 18
2.4........ Affected groups and regions.......................................................................................... 21
2.5........ Justification for EU action.............................................................................................. 22
2.5.1..... The EU’s right to act..................................................................................................... 22
2.5.2..... Added value of EU action............................................................................................. 22
2.6........ Baseline scenario.......................................................................................................... 24
3........... DEFINITION OF POLICY
OBJECTIVES............................................................. 27
3.1........ General objective.......................................................................................................... 27
3.2........ Specific objective......................................................................................................... 27
3.3........ Operational objectives.................................................................................................. 27
3.4........ Consistency of objectives with EU
strategic objectives................................................... 27
3.5........ Coherence of objectives with
those of other policies...................................................... 28
4........... POLICY OPTIONS................................................................................................... 29
5........... ANALYSIS OF IMPACTS AND OF
EFFECTIVENESS....................................... 33
5.1........ Social impacts.............................................................................................................. 33
5.2........ Economic impacts......................................................................................................... 36
5.3........ Environmental impacts.................................................................................................. 41
5.4........ Analysis of effectiveness................................................................................................ 42
5.4.1..... Option A: baseline scenario........................................................................................... 42
5.4.2..... Option B: Push for increased
policy co-ordination......................................................... 43
5.4.3..... Option C: Push for increased
policy co-ordination and monitoring, based on key elements of the EU Physical
Activity Guidelines........................................................................................................ 45
5.4.4..... Option D: Push for increased
policy co-ordination and monitoring, based on implementing all 41 EU Physical
Activity Guidelines........................................................................................................ 46
5.5........ Analysis of impacts per option....................................................................................... 48
6........... COMPARISON OF THE OPTIONS....................................................................... 51
6.1........ Effectiveness................................................................................................................. 51
6.2........ Feasibility of implementation and
sustainability............................................................... 51
6.3........ Efficiency...................................................................................................................... 52
6.4........ Coherence.................................................................................................................... 54
7........... SUMMARY: COMPARISON OF
OPTIONS........................................................ 55
7.1........ The preferred option..................................................................................................... 55
8........... MONITORING AND EVALUATION.................................................................... 56
9........... ANNEX I: CONSULTATION
OUTCOMES.......................................................... 57
9.1........ Member States (Council
structures, informal level)......................................................... 57
9.1.1..... EU structures for sport.................................................................................................. 57
9.1.2..... EU structures for health................................................................................................. 63
9.2........ The European Parliament.............................................................................................. 68
9.3........ HEPA Experts.............................................................................................................. 69
9.4........ Stakeholders and the general
public............................................................................... 73
10......... ANNEX II: ADDITIONAL EVIDENCE
ON PHYSICAL ACTIVITY IN THE EU 74
10.1...... The benefits of physical activity
and detriments caused by physical inactivity................... 74
10.2...... The persistent lack of physical
activity in the EU............................................................ 74
11......... ANNEX III: MONITORING
FRAMEWORK AND PROPOSED TABLE OF INDICATORS          74
11.1...... Introduction.................................................................................................................. 74
11.2...... Identifying indicators to monitor
the implementation of the EU PA GL (in line with the preferred policy option in
the IA)............................................................................................................................... 74
11.3...... Overview of proposed indicators
for the monitoring of the implementation of the EU PA GL    74
11.4...... Operationalization, methodology
and data by proposed indicator................................... 74
11.5...... Key information sources............................................................................................... 74
12......... ANNEX IV: DIAGRAM (PHYSICAL
ACTIVITY MONITORING UNDER A RECOMMENDATION ON HEPA, AS OF MID-2014)................................................................................. 74
13......... ANNEX V: COSTS TO THE EU
BUDGET AND ADMINISTRATIVE COSTS IN THE MEMBER STATES..................................................................................................................... 74
13.1...... Costs to the EU budget................................................................................................. 74
13.2...... Administrative costs in the Member
States..................................................................... 74
List
of tables used in the Impact Assessment
·                        
Table 1:          Impact assessment procedural
steps
·                        
Table 2:          Overview consultations
·                        
Table 3:          Policy options to be assessed
·                        
Table 4:          Economic value of increased
HEPA levels
·                        
Table 5:          Administrative costs in the
Member States 
·                        
Table 6:          Impact on EU budget 
·                        
Table 7:          Effectiveness Option A 
·                        
Table 8:          Effectiveness Option B
·                        
Table 9:          Effectiveness Option C
·                        
Table 10:        Effectiveness Option D
·                        
Table 11:        Analysis of impacts per option
·                        
Table 12:        Cost-effectiveness
·                        
Table 13:        Comparison of options
List
of figures used in the Impact Assessment
·                        
Figure 1:         Future priorities for EU
action in the field of HEPA
·                        
Figure 2:         Evolution of the proportion of
Finns engaging in twice per week leisure time physical activity
·                        
Figure 3:         Estimated economic savings
through rising levels of physical activity
Abbreviations:
 EC/COM || European Commission 
 DG EAC || Directorate General for Education and Culture 
 DG SANCO || Directorate General for Health and Consumer Affairs 
 EU || European Union 
 EUR || Euro/s 
 EU PA GL || EU Physical Activity Guidelines 
 GBP || Pound sterling 
 GDP || Gross domestic product 
 GPAQ || Global Physical Activity Questionnaire 
 HEPA || Health-enhancing physical activity 
 HEPA Europe || European network for the promotion of health-enhancing physical activity 
 HLG || High Level Group for Nutrition and Physical Activity 
 IA || Impact Assessment 
 IPAQ || International Physical Activity Questionnaire 
 MS || Member State/s 
 NCD || Non-communicable disease 
 NGO || Non-governmental organisation 
 NOPA || European Database on Nutrition, Obesity and Physical Activity 
 OMC || Open method of coordination 
 PA || Physical activity 
 PAT || Policy Audit Tool 
 TFEU || Treaty on the Functioning of the European Union 
 WG WHO XG SHP || Working Group World Health Organization Expert Group on Sport, Health and Participation 

Definitions:
Various physical activity ‘guidelines’
and ‘recommendations’ are mentioned throughout this report. In order to
avoid any confusion of terms, documents which focus solely on the amount of
physical activity that is necessary to achieve certain health effects on the
individual level are referred to as physical activity ‘recommendations’. The
term ‘guidelines’ is thus reserved for documents that advise policy makers how
to take action on a certain topic.
The term ‘monitoring’ is used
throughout the main body of this report to refer to the collection of data on
physical activity and / or the implementation of policy. ‘Surveillance’ often
takes this meaning in a public health context, but is not used due to the
context and audience of this report. However, it is employed in many of the
sources cited herein.
This IA uses the term ‘sport’ in
line with the definition established by the Council of Europe in its 1992
European Sport Charter and used by the Commission in its 2007 White Paper on
Sport: "Sport means all forms of physical activity which, through casual
or organised participation, aim at expressing or improving physical fitness and
mental well-being, forming social relationships or obtaining results in
competition at all levels."
The term ‘physical activity’ is used
in line with the definition established by the World Health Organization (WHO)
according to which “Physical activity is defined as any bodily movement
produced by skeletal muscles that requires energy expenditure. Regular moderate
intensity physical activity – such as walking, cycling, or participating in
sports – has significant benefits for health.”
1.           PROCEDURAL
ISSUES AND CONSULTATIONS
1.1.        Identification
Lead service: DG EAC.D.2 (Sport Unit)
Main
associated service: DG SANCO
Other
services involved: SG, SJ, DG BUDG, DG COMM, DG
EMPL, DG ENV,
DG ESTAT, DG JUST, DG MOVE, DG REGIO, DG RTD
Agenda Planning: 2013/EAC+/013
Subject: Proposal for a Council
Recommendation on health-enhancing physical activity (HEPA)
1.2.        Organisation
and Timing
Table 1:
Impact assessment procedural steps
 Action/Steps || Date 
 1st meeting of the Inter-Service Steering Group (ISSG) - discussion of the IA Roadmap || 19 July 2011 
 Finalisation of Roadmap || September 2011 
 Bilateral consultation with DG SANCO – focus on first part of the IA || 3 May 2012 
 2nd ISSG meeting – focus on first part of the IA and draft indicators || 12 June 2012 
 Updated Roadmap[1] || September 2012 
 Bilateral consultation with DG SANCO – focus on monitoring framework || 3 October 2012 
 3rd ISSG meeting – discussion of draft final IA || 24 October 2012 
 Submission of IA Report to Impact Assessment Board (IAB) || 7 November 2012 
 IAB meeting || 5 December 2012 
 IAB opinion || 7 December 2012 
1.3.        Impact
Assessment Board (IAB)
The IAB, in its opinion on the draft of this Impact Assessment, recommended
DG EAC to provide additional explanations why the EU and the Member States had
failed to increase HEPA rates and how the EU could help in that respect. To
reflect the Board’s comments, DG EAC has included additional information and
improved the intervention logic of this IA report. In line with the Board’s
suggestions, an additional effort was made to better explain the policy options
and to provide a realistic assessment of impacts. Moreover, an effort was made
to follow the Board’s advice to better reflect stakeholders’ opinions. 
1.4.        Consultations
Over the past
years, Member States, experts, sport stakeholders and the general public have
been consulted at different levels on their views regarding the need of and
scope for the promotion of physical activity in an EU context, either directly
or indirectly related to the planned EU policy initiative on health-enhancing
physical activity (HEPA). After the adoption of the Communication on sport in
January 2011 that includes an action point to consider such a proposal, the
Commission has regularly presented its plans and the work in progress for this
initiative to the policy level, to stakeholders and to experts and sought
feedback within different settings. The table below provides an overview of the
main discussion fora and of the level of stakeholders consulted. A detailed
summary of the consultations can be found in Annex I of this report to explain
who was consulted and with what results relevant to this initiative, in
particular also regarding the envisaged monitoring framework. The minimum
consultation standards have been respected. Views from the below fora and
meetings have informed all main parts of this IA, in particular the problem
section but also the development of the main ideas for the initiative,
including the monitoring framework, which this IA will assess in detail.
Table 2:
Overview consultations
 Actors consulted || Meetings/Fora 
 Member States       - Work in the Council       - Work at the informal level || §   Preparation of the Council Resolution on an EU Work Plan for Sport adopted on 11 May 2011 (Working Party on Sport / EYCS Council) and its implementation §   Preparation of Council conclusions on HEPA adopted in November 2012 (Working Party on Sport / EYCS Council) §   Expert Group “Sport, Health and Participation” set up by the Council (4 meetings as of autumn 2011) §   Preparation of Council conclusions in the field of health (2011, 2012) 
 §   Meetings of EU Sport Ministers in 2011 and 2012 §   Meetings of EU Sport Directors in 2011 and 2012 §   High Level Group on "Nutrition and Physical Activity" (meetings of 3 February 2011 and 14 June 2012) 
 European Parliament || §   Preparation of the EP Resolution on the European dimension in sport (adopted on 2 February 2012) 
 HEPA Experts || §   Annual meetings of the HEPA Europe network 2008-2012 (incl. meetings of the HEPA Europe EU contact group as of 2010) §   Workshop on indicators, 29 February 2012 
 Sport stakeholders and general public || §   EU Sport Forum 2012 (Nicosia) §   Expert meeting, 19 September 2012 §   Sportvision2012 – DK Presidency Conference §   EU Platform for Action on Diet, Physical Activity and Health §   Online consultation to implement the Lisbon Treaty in the field of sport, Feb.-April 2010 
1.5.        Use
of external expertise
As part of the preparations for this
initiative DG EAC commissioned a study to assist it with specific elements, in
particular the development of the envisaged monitoring framework including a
set of indicators. The latter is proposed to form the core part of the planned
Council Recommendation on HEPA. The study consortium (The Evaluation
Partnership - TEP, the University of Zurich and VU University Medical Center)
combines experience in evaluating EU initiatives and expertise in the field of
HEPA. Work on the study started in October 2011 and was finalised a year later.
2.           PROBLEM
DEFINITION 
2.1.        Context
2.1.1.     The
importance of physical activity[2]
Physical
activity, including regular sporting practice and exercise, across the life
course is one of the most effective ways of staying physically and mentally
fit, combating overweight and obesity and preventing related conditions. In
addition, participation in sport and physical activity is correlated with other
factors such as social interaction and enjoyment[3].
The myriad benefits of physical activity are well recorded and include
lowered risk of cardiovascular disease, some cancers and type-2 diabetes,
improvements in musculoskeletal health and body weight control[4]. There is also a growing body
of evidence on the positive correlation between exercise and mental health,
mental development and cognitive processes[5], including the
fact that physical activity mitigates both the development and the effects of
chronic stress. Mirroring these benefits is a requisite set of detriments
caused by the lack of physical activity, including premature mortality[6], rising overweight and obesity
levels, particularly among children, as well as a number of health problems
aside from obesity (e.g. breast and colon cancers, diabetes, ischaemic heart
disease). Available evidence also shows that the various health problems caused
by the lack of physical activity have significant economic costs,
especially in view of the fact that most European societies are ageing rapidly.
Apart from these far-reaching negative health and economic effects, physical
inactivity also has environmental and social implications.
2.1.2.     Policy
context
As awareness of the importance of physical activity has grown, many
public authorities at the local, regional, national, European and international
levels have stepped up their efforts to promote health-enhancing physical
activity (HEPA). As sport and health policies are primarily national
competences, it is within individual Member States (MS) that the most
important efforts to promote HEPA are being made. As of 2010 a large majority
of EU MS reported to have at least some form of guidelines or recommendations
in place for physical activity[7] to enable and encourage
their populations to become more physically active. Specific measures for this
purpose have been launched in a number of policy areas or sectors, in
particular sport, health, transport and education.[8]
At the international level, the World Health Organization
(WHO) adopted a Global Strategy on Diet, Physical Activity and Health in May
2004 aimed at reducing risk factors for chronic diseases that stem from (…)
physical inactivity.[9]
The Action Plan for the Global Strategy for Prevention and Control of Non-communicable
Diseases[10]
(NCDs) 2008-2013 calls for the implementation of actions in line with the
strategy.[11]
The WHO has also developed Global Recommendations which recommend at least 150
minutes per week of moderate-intensity physical activity for adults.[12]
In September 2011, a political declaration of the UN high-level meeting of the
General Assembly on the Prevention and Control of NCDs recognised that the most
prominent NCDs are linked to four common risk factors, including lack of
physical activity, and strived at further advancing the implementation of the
WHO Global Strategy, including the introduction of policies and actions aimed
at increasing physical activity in the entire population.[13] Voluntary targets for the
prevention and control of NCDs by 2025 have been agreed in the WHO global
monitoring framework, including a 10% reduction in prevalence of insufficient
physical activity.[14]
In Europe, the WHO Regional Office for Europe has played a key role through
HEPA Europe, a collaborative project established in 2005 with the aim of strengthening
and supporting efforts to increase physical activity.[15] In November 2006 WHO Europe
adopted the European Charter on Counteracting Obesity, which calls for a
package of preventive actions relating to nutrition and physical activity. The
Second European Action Plan on Food and Nutrition Policy (2007-2012) contains
actions to tackle four main health challenges including physical inactivity.[16] The Action Plan for
implementation of the European Strategy for the Prevention and Control of NCDs
2012-2016 takes account of the fact that physical activity is influenced by
urban environments and transport policies and also calls for supporting
interventions to promote active mobility.[17]
At EU level physical activity has
been promoted through different competences and instruments. The lack of
physical activity is being addressed through action in the policy area of
sport which inter alia has the advantage of drawing on the potential of
sport stakeholders to reach large parts of the EU population, including inactive
people[18].
An informal EU Working Group “Sport and Health”, open to all MS, was launched
in the second half of 2005. The 2007 White Paper on Sport highlighted the
importance of physical activity, stipulated that the COM would facilitate the
exchange of information and good practice for HEPA, and set out a plan for the
COM to propose physical activity guidelines by the end of 2008.[19] These guidelines – known as
the EU Physical Activity Guidelines (EU PA GL) – were drafted by a group
of 22 experts from around Europe representing various disciplines and broadly
representative of informed scientific opinion, approved by the Working Group on
Sport and Health, and endorsed by EU Sport Ministers in November 2008.[20]
They reiterate WHO Recommendations on the minimum level of physical activity,
emphasise the importance of a cross-sectoral approach and provide 41 guidelines
covering the relevant sectors responsible for HEPA promotion. The 2011
Communication on sport[21]
pointed out that “physical activity is one of the most important health
determinants in modern society” and that “sport constitutes a fundamental part
of any public policy approach aiming at improving physical activity”. MS and
the COM were invited to “based on the EU PA GL, continue progress toward the
establishment of national guidelines, including a review and coordination
process”. In response to the Communication, in May 2011 the Council agreed an
EU Work Plan for Sport for 2011-2014[22]
that recognised the need to strengthen co-operation between the COM and MS in
sport, defined priority themes, including HEPA, and established several Expert
Groups, including an Expert Group on Sport, Health and Participation (XG SHP)
that got the mandate to “explore ways to promote HEPA and participation in
grassroots sport”. The Group’s first set of deliverables was presented to the
Council in July 2012 and provided input to the planned initiative.[23]
On the health policy side, physical
inactivity has been addressed in relation to the epidemic of overweight and
obesity, based on the 2007 White Paper on a Strategy for Europe on Nutrition,
Overweight and Obesity-related health issues[24] that aimed at
encouraging co-operation between MS and supporting them in their efforts to
encourage healthier eating habits as well as HEPA. This Strategy outlines key
principles for action, reiterated the importance of an effective partnership
approach between different levels of government as well as different sectors of
society, and emphasised the need for policy coherence across various policy areas
including sport and physical activity. In particular a High Level Group on
Nutrition and Physical Activity (HLG), consisting of European government
representatives and chaired by the COM, was set up. Its aim has been to help
share information on policies, policy ideas and practices. Among the strategy's
implementation tools, there is the EU Platform for Action on Diet, Physical
Activity and Health launched in March 2005 in order to create a forum for
cross-sectoral co-operation between relevant private sector and
non-governmental actors at European level willing to commit to tackling current
trends in diet and physical activity.
As far as funding is concerned, projects
promoting physical activity have been supported under various EU programmes,
including the Health Programme (2008-2013), the Lifelong Learning Programme
(2007-2013), the framework programmes for research[25] and also under the Preparatory
Actions in the field of sport (2009, 2012). Regarding future programmes, it should
be noted that the proposed Erasmus+ Programme 2014-2020 foresees €238 million
of funding for European cooperation in sport, with HEPA being a priority area
for action.[26]

2.2.        Identification
and analysis of the main problem(s)
In spite of the growing profile given to
physical activity promotion in the political debates at MS as well as
international and EU levels and available tools to promote HEPA (as described
under 2.1.2), the rates of physical inactivity in the EU remain unacceptably
high. The available EU[27]
and national data outlined in Annex II shows that the vast majority of
Europeans do not engage in sufficient HEPA (e.g. in 2010, 60% of Europeans
responded that they exercise or play sport seldom or never).[28] It also demonstrates vast
discrepancies between individual MS. This situation runs not only counter to
the Europe 2020 Strategy[29], which acknowledges the
need to fight health inequalities as a prerequisite for growth and
competitiveness, but is also incompatible with the EU's stated policy ambitions
in the fields of sport and health.
HEPA promotion depends primarily on efforts
within MS at national, regional and local levels. However, most MS have not
achieved the principal policy objective in this area, namely to increase the
proportion of citizens who reach the HEPA levels recommended by the WHO, and
reiterated in the EU PA GL. The main problem to be addressed by the initiative
therefore is that in general, the HEPA promotion policies of EU MS
have not been effective (although there are notable exceptions[30]). 
The often
disappointing results in the evolution of HEPA participation rates raises the
question of why the HEPA promotion policies adopted by most MS have so far
not delivered the desired results.[31]
The reasons for the low effectiveness of MS policy are above all shortcomings
in the way HEPA promotion policies are developed and implemented within
individual MS. 
To determine the main shortcomings, it is
first useful to outline what is meant by ‘effective’ HEPA policy. At European
level, the criteria to define effective HEPA policy are laid out in the
EU PA GL.[32]

EU Physical Activity Guidelines
“It is only possible to reach the set
targets through inter-ministerial, inter-agency and inter-professional
collaboration, including all levels of government (national, regional, local),
and in collaboration with the private and voluntary sectors.”
“Increasing the levels of physical activity
falls within the remit of several important sectors, most with a major public
sector component:
- Sport
- Health
- Education
- Transport, environment, urban planning
and public safety
- Working environment
- Services for senior citizens”
Most
importantly, these GL emphasise that a cross-sectoral approach to HEPA policy
is an absolute necessity, that “Targets and objectives are not enough to ensure
effective implementation of national Physical Activity Guidelines”, and that
national HEPA policies should be based on “the following quality criteria that
have shown to increase the potential for effective policy implementation:”
·                        
Developing and communicating concrete goals,
objectives and target groups;
·                        
Planning concrete steps, timeframes and
milestones for implementation;
·                        
Defining clear responsibilities for implementation;
·                        
Allocating sufficient financial and human
resources at all relevant levels;
·                        
Creating a supportive policy environment with
support from key actors across all relevant sectors and at all levels;
·                        
Increasing support from the public and specific
target groups through effective communication;
·                        
Monitoring and evaluating the implementation and
outcomes of the policy in a robust and systematic way.
Hereafter
those criteria for effective HEPA policy are examined which the MS have
evidently had the least success in implementing on a wider scale (several
exceptions notwithstanding). The available evidence[33] confirms the existence of shortcomings
in at least three aspects of HEPA policy that are interconnected: the cross-sectoral
approach and collaboration among different ministries and bodies
responsible for HEPA promotion; objective setting; and monitoring
and evaluation. 
2.2.1.     Approach
to HEPA not sufficiently cross-sectoral 
The lack of a
sufficiently cross-sectoral approach is the most clearly identifiable problem
in the national HEPA policy of a large number of MS, a tendency that is evident
in the findings of several recent studies (e.g. the 2012 Lancet series, see fn4)
and was confirmed in the consultations with national policy makers, experts and
other relevant stakeholders.
One study
consisted of an in-depth examination of 27 policy documents from 14 countries
including 11 EU MS.[34] It confirms that each
individual Ministry tends to have its own agenda when it comes to taking action
to promote physical activity. The assessment revealed a lack of cross-sectoral
collaboration at both the policy development and implementation stages. For
example, the paper cites only ‘limited evidence for intersectoral collaboration
in the preparation of the policies between ministries and in most cases the documents
had been prepared by a single ministry alone.[35] Moreover, while some policy
documents involved authorities or bodies besides the lead ministry, one third
were prepared without any form of collaboration at all. This lack of
collaboration extended to plans for implementation. Nearly one third of the
documents involved only one ministry or authority in policy implementation,
while the majority required collaboration between a maximum of two actors.[36] Clearly, “the mere existence
of a national physical activity policy or action plan does not secure its
functionality or implementation”.[37]
A tool for collecting comprehensive data on HEPA policy, the HEPA
Policy Audit Tool (HEPA PAT), coordinated by WHO Europe, also demonstrates the
insufficiently cross-sectoral approach to physical activity promotion taken by
countries. Crucially, the HEPA PAT allows a distinction to be drawn between
‘theory’ and ‘practice’. All seven countries that completed the HEPA PAT (FI,
IT, NL, NO, PT, SI and CH) reported some degree of formal consultation
in the formulation of government policy.[38]
Examining the completed HEPA PATs collectively, it is clear that, despite
good-practice exceptions (e.g. Finland and the Netherlands), active
collaboration and coordination between all relevant and responsible
ministries and other authorities / organisations are rare and often not
sustained. The HEPA PAT data also shows that government officials in fields
that have only recently taken on some responsibilities to promote HEPA, such as
transport and education, have not fully benefited from the expertise of other
sectors, such as public health, where the importance of HEPA is more firmly
established.
 Finland’s cross-sectoral approach Many national-level ministries and agencies in addition to local authorities and rural communities all share responsibility for physical activity promotion and the funding of HEPA programmes. In order to ensure collaboration and cooperation among these different actors, Finland has: –                         Issued a political resolution on HEPA and diet to consolidate existing documents, define the political direction and over-arching goals across sectors; –                         Set up advisory committees consisting of members from national ministries, local authorities, NGOs and research institutes; –                         Consulted relevant organisations during the development of policies. While cross-sectoral collaboration is still considered a challenge, this approach has succeeded in securing wide participation in the policy-making process and incorporating HEPA across all the sectors concerned. 
Relevant governmental and non-governmental
stakeholders consulted for this IA, echoed these findings: lacking
cross-sectoral cooperation was cited as the key obstacle to effective
physical activity promotion.[39]
A recent
large-scale study of policy documents from all EU MS[40]
serves to add weight to this argument. The study compiled and examined policy
documents related to HEPA promotion from 26 MS, and categorised them
according to the sectors concerned. The data indicates that while nearly all
countries (25) have public health policies in place which promote HEPA,
and 16 promote HEPA through sport policy, only ten countries have transport
policies that explicitly refer to HEPA. Few MS pursue HEPA through other policy
areas: only five countries had specific education policies with goals
relating to HEPA,[41] while four countries
have produced documents making the link between physical activity and the environment.
The analysis shows that in the vast majority of countries HEPA is included in
policy documents covering a maximum of three policy areas, while hardly any
MS approach HEPA policy from four or five policy areas. 
The lack of
effective collaboration and coordination even extends to individual policy
sectors. The sport sector, one of the key players in any successful effort
to promote HEPA, has in some cases been singled out for prioritising elite
sport at the expense of grassroots sport and sport for all, despite the
benefits of the latter in terms of promoting physical activity. This was
highlighted, for instance, at the last meeting of the EU WG on Sport and
Health.[42]
Although the organisation of sport in Europe (as described in the White Paper
on Sport) demonstrates the complementary relationship between elite and
grassroots sport, representatives from the sport for all movement have
regularly expressed concerns[43]
that the sport sector does not make the link strongly enough. This, inter alia,
prevents the sport sector, and policies targeting elite sport, from achieving
their potential impact in terms of increasing physical activity among the wider
citizenry and contributing to health – a potential outreach which cannot be
replicated in other policy sectors. It was suggested, e.g. at the
abovementioned meeting, that the coordination between the different parts of
the sport sector needed to be reinforced. 
A recent
public consultation[44] demonstrates that
concerns about lacking cross-sectoral collaboration on HEPA resonate with a
broad cross-section of interested stakeholders. Asked to express the extent of
their agreement with several statements relating to physical activity promotion
by public authorities and sport organisations, a strong majority of respondents
felt that public authorities do not give enough support to physical activity,
and that there is not enough physical activity in education.
2.2.2.     Objectives
and goals not concrete and clear enough
The available
evidence also suggests that many MS do not define the objectives of
their HEPA policies clearly and concretely enough, and tend not to develop
sufficiently measurable indicators to track progress (see also the sub-chapter
on monitoring and evaluation below). The study of 27 policy documents cited
above shows that very often, objectives listed were vague (e.g. ‘to stimulate
the practice of regular physical activity in the population’). Quantifiable
targets to achieve stated goals only existed for 22% of the documents analysed,
and examples of good practice (e.g. by 2010, at least 65% of the adult
population will meet the exercise standard) were rare. Hardly any policies made
specific provisions for targeting groups with particularly low levels of
physical activity, such as individuals of low levels of education and / or
income. 
A recent
analysis of national sport strategies and policies undertaken as part of the
COM-funded Net-Sport-Health project[45] paid particular attention
to targets and indicators, and unearthed similar results. All 25 of the
documents[46] examined, which covered
the national and sub-national level for 15 MS, contained (at the least) broad
goals which made the link between physical activity and health for the
wider population. However, hardly any countries (i.e. three) identified
quantifiable targets relating specifically to physical activity and health,
while only one policy document was described as ‘fully adhering to the
requirements of Specific, Measurable, Attainable, Relevant and Timely
(SMART) targets’. 
2.2.3.     Insufficient
provisions for monitoring and evaluation
Collecting,
recording and publicising comprehensive data on physical activity are crucial
features for the effective monitoring of HEPA and evaluation of policies aimed
at promoting physical activity. However, an examination of current practice
reveals significant shortcomings in the majority of MS. This is at least partly
due to the lack of cross-sectoral coordination, as various actors collect
similar but incomparable data and / or fail to share data while precluding the
critical mass (both in terms of expertise and budgetary capacity) necessary to
employ suitable methodologies. 
Regarding monitoring
of HEPA participation rates, there is no data that is comprehensive and
comparable across countries. Although the WHO has issued concrete
recommendations for the effective monitoring of physical activity on the basis
of the standardised IPAQ and GPAQ questionnaires,[47]
the data collected for the NOPA database[48] indicates
that only eight EU MS have included the IPAQ in national surveys, while
just one has made use of the more exhaustive GPAQ. Moreover, hardly any of
these MS repeat the exercise at regularly defined intervals, making it
difficult to ascertain trends and gauge progress and / or the success of HEPA
promotion policies over time. Some countries had systems in place to
produce comparable data on changes to physical activity, while others altered
survey questions and methodologies year on year or did not have any such
systems in place. While there are a number of MS (most notably the United
Kingdom, Finland and the Baltic countries) which carry out extensive and
periodic surveys of physical activity outside the IPAQ, variations in methodology
render statistical comparison between countries impossible. 
With regard to
policy evaluation, the above-mentioned Net-Sport-Health project found
that although about two-thirds of the national strategies did set out
requirements for evaluation, many of these lacked detail. For example,
only a small number of national strategies called specifically for periodic
reports on progress, while measurable outcome indicators were not provided in
the majority of cases. The detailed analysis of national policies in a few
countries demonstrates a similar set of issues.[49] Generally, concrete goals and
performance indicators, and specific plans for measuring the success of
specific policies, were vague or non-existent.
MS representatives and experts have
expressed similar views regarding data availability, describing current
monitoring and evaluation practices as inadequate for gauging progress or
making comparisons across countries.[50]
2.3.        Underlying
reasons for the main shortcomings
There is a clear gap between the available evidence
(benefits of physical activity; cost burden posed by present levels of
inactivity; effective interventions) on the one hand, and subsequent policy
action to address physical inactivity, on the other. [51] The question arises what has
prevented MS to develop more effective HEPA promotion policies or why the role
of physical activity has been undervalued.
The underlying reasons are likely to relate
to the fact that HEPA is only starting to become a focused policy field on
its own and to get recognition as a complex policy area that requires
multi-sectoral interventions, such as those provided for in the EU PA GL.
Physical activity has so far not enjoyed advocacy power comparable with
e.g. the mobilisation of tobacco control to ensure that it receives the
appropriate political recognition.[52]
‘Integrated approaches’ at the international level have helped to bring
physical activity on the policy agenda. For instance, physical activity has
been coupled with ‘diet’ to address obesity[53]
or treated as a risk factor among others in the debate on NCDs[54] (see sub-chapter 2.1.2).
However, physical activity has not been considered as a stand-alone topic
requiring specific approaches, despite evidence for many independent health
effects and other effects beyond health.[55]
Today, scientists therefore call for a ‘specific policy focus on
physical activity to tackle physical inactivity’ and to act now.[56]
While HEPA as a policy field is a rather new
topic on the agenda of governments (if at all), understanding
of the determinants of HEPA, which is essential for designing interventions to
change physical activity levels, is even younger.[57] As a consequence, intersectoral capacities[58], improved
understanding and institutional structures are still lacking in most MS to promote HEPA, in particular in those with the highest
inactivity rates, in contrast with e.g. nutrition where most countries even have
special academic curricula. This was confirmed in the discussions with public
authorities and is consistent with the observation that
on the occasion of international consultations related to obesity, nutrition
and physical activity most MS participated with much stronger expertise related
to nutrition (a field scientifically “mature” and historically well established
in the institutional infrastructure of MS) than to physical activity (a
discipline under rapid scientific development, and a relatively new area of
interest for public health).[59]
It is furthermore confirmed by the fact that whenever
international institutions have called upon MS to appoint counterparts on physical
activity, appointees were generally not experts in HEPA promotion but rather in
nutrition or other related fields.[60]
Evidence shows that countries with institutional capacity to promote HEPA (e.g.
FI or NL) are doing better than those without it (e.g. CY or HU).
Another underlying reason for ineffective
HEPA policies relates to budgetary constraints in the crisis context.
Despite the urgent need for action, policy makers might have been tempted to
give low priority to HEPA policy development and implementation. The
current economic situation could have led MS to allocate insufficient financial
and human resources to effective HEPA promotion – such cuts have, for instance,
been reported for national sport departments[61].
HEPA promotion requires investments in the short term that only deliver health
and economic benefits to the MS in the medium to long term. It could well be
that a majority of EU MS has not been sufficiently aware of the need to design
and make well-targeted multi-sectoral investments today to benefit from
positive longer-term effects in the future, or, as outlined above, lacked
the capacity or the available data to do so. Only some MS have taken full
advantage of the ‘low-hanging fruit’ (e.g. FI).
The above situation is partly also
reflected in the EU’s activities and structures dealing with physical
activity. While physical activity has been promoted in different policy fields
and helped give attention to the HEPA topic (see chapter 2.1.2), no single coordinated
approach on HEPA exists that would encompass the relevant policy sectors
and take into account the multiple effects of physical activity in the field of
health and beyond. It is an achievement that physical activity could be brought
on the EU agenda in the context of the Strategy on Nutrition, Overweight and Obesity-related
health issues. However, due to the fact that physical activity was coupled
with another public health issue (diet/nutrition) to which MS have attached
great(er) importance, a focused approach to tackling physical inactivity has
not yet been developed.[62]
Moreover, the important prevention and rehabilitation effects of physical
activity tend to be neglected in other policy initiatives, for instance those
aiming to address the wider economic and social challenges for the EU, such as
the ageing population, where the focus has rather been on medical treatment and
IT solutions instead of "smart investment" in physical activity.[63] No consistent approach exists
either in the EU's cohesion policy that would reflect the importance of
investing in physical activity and that could help address the regional
dimension of low HEPA rates and corresponding investment levels in the MS. With
the development of the EU PA GL, an effort was made to give a specific policy
focus to the promotion of HEPA. While some progress could be achieved at the EU
policy level in promoting the GL further (e.g. in policy discussions and recent
Council conclusions) they have not yet been implemented effectively at national
level.[64]
Partly linked to the lack of a focused approach to HEPA at EU level involving
coordination between different policy sectors (e.g. sport, health, education,
transport) and their working structures, opportunities for promoting the GL
within relevant policies beyond sport have been missed out. There is considerable
scope in EU policy making to encourage the implementation of the GL as a means
for effective HEPA promotion and to improve existing forms of policy
cooperation between the MS at EU level to help reverse the trend regarding
physical inactivity. Indeed, to date, no policy coordination, neither within
the EU’s approach nor between MS at EU level, exists that would sufficiently
reflect the complexity of the HEPA topic as a differentiated (focused) policy
area.[65]
A continuation of the current situation would
not address the ineffectiveness of MS' HEPA policies since the main problem
drivers (missing advocacy power behind HEPA, lack of intersectoral capacities
and understanding in MS, no focused policy approach on physical activity and no
coordinated policies at EU and MS level) would only marginally be addressed
which means that the aspects of HEPA policy identified above (relating to
cross-sectoral approach, objective setting, monitoring) would continue to be problematic.

2.4.        Affected
groups and regions
The planned initiative will first and foremost target public
authorities in EU MS responsible for HEPA promotion and more specifically
the thematic areas covered by the EU PA GL, including those key areas for which
the initiative will propose specific monitoring activities. Accordingly, the
initiative should help improve capacity to promote HEPA more effectively across
sectors and will at least concern authorities in charge of the following areas:
sport, health, education, transport environment, urban planning, public safety,
working environment and services for senior citizens. It will in particular
focus on those MS that have been less successful in raising HEPA levels of
their citizens (generally these are countries in southern and eastern Europe)
and thereby address regional disparities within the EU-28.
The implementation of the proposed Council Recommendation will have
a direct impact on certain sectors of society, such as the sport or the
health care sectors that will be encouraged to follow the Guidelines to promote
physical activity within the sphere of their activities and competences. The
initiative will also rely on mobilising stakeholders, including the ones most
directly related to physical activity and with strong assets to reach out to
citizens with targeted offers, i.e. the sport movement.
Ultimately, the proposed initiative aims at reaching out to EU
citizens at large (e.g. children, working population, seniors) by providing
new opportunities to engage in physical activity in accordance with WHO
recommendations. Since the lack of physical activity is particularly pronounced
among specific at-risk-groups of the population (socio-economically
disadvantaged groups, women, children and the elderly), the benefits of the
initiative would accrue to these groups to a greater degree than to Europeans
as a whole.
2.5.        Justification
for EU action
2.5.1.     The
EU’s right to act
The EU has the
right to act in the field of HEPA based on two Articles of the Treaty on the
Functioning of the EU (TFEU), both of which assign a supporting competence to
the EU. Article 165 stipulates that the Union shall ‘contribute to the
promotion of European sporting issues’ and that action shall be aimed at
‘developing the European dimension in sport’. Article 168 stipulates
that ‘Union action [...] shall be directed towards improving public health
[...] and obviating sources of danger to physical and mental health’. This
covers inter alia health information and education and monitoring. The Article
also stipulates that the EU shall ‘encourage co-operation between the MS and,
if necessary, lend support to their action’. By doing so, in line with the Treaty,
the EU has to respect the responsibility of the Member States for the
definition of their health policies.
In both areas
(sport and public health), the TFEU states that in pursuit of these objectives,
the European Parliament and Council may adopt incentive measures, and
that the Council (on a proposal from the COM) may adopt recommendations.
In addition, the Treaty explicitly authorises the COM to take ‘any useful
initiative’ to promote policy co-ordination among the MS in the area of
public health, in particular ‘initiatives aimed at the establishment of
guidelines and indicators, the organisation of exchange of best practice, and
the preparation of the necessary elements for periodic monitoring and
evaluation’.
2.5.2.     Added
value of EU action
As regards the
application of the subsidiarity principle, there can be no doubt that
the main responsibility for promoting HEPA lies with the MS. Thus, the question
is whether the EU action can add significant value, over and above what MS
would be able to achieve on their own.
This question
should be answered in the affirmative. On a very general level, EU support for
more effective HEPA promotion policies can help reduce the significant social
and economic costs of physical inactivity for all MS, and thus strengthen their
ability to achieve the growth objectives set in the Europe 2020 Strategy.

EU action has the potential to render MS
efforts to promote HEPA both more effective and more cost effective than
would be possible otherwise. In line with the international framework and
actions to promote physical activity, the EU can provide renewed political
momentum to focused action on HEPA in the EU-27 and raise awareness of the need
to act now.[66]
The EU can, in line with its supporting and coordinating competences in the
fields of sport and of health, facilitate and strengthen policy co-ordination
by helping MS to share information and experience, engage in peer learning,
disseminate good practice and work together to develop common approaches, and
thereby contribute to improving capacity to promote HEPA across sectors
and to shape policies that ensure better interventions.[67] In particular in the current
crisis context, the EU could help the MS in developing and implementing
effective policies for HEPA promotion, e.g. by enabling them to make
well-targeted interventions in the shorter term designed to avoid future
harmful economic and social consequences resulting from physical inactivity. A
number of MS consider such co-ordination in the area of
HEPA particularly useful given the vast differences that currently exist between them in terms of the
amount of priority afforded to HEPA to date, the approaches chosen, the
national policy co-ordination mechanisms and the cultural and economic
differences and similarities between MS that have an effect on HEPA rates and
point to measures that may be most promising.[68]

Moreover,
exchange of best practices is significantly strengthened when there is actual
evidence as to the effectiveness of different measures and policies. The EU is
well situated to enhance provisions for monitoring and evaluation of HEPA
and HEPA policies and thereby help the MS to track developments over time. As
pointed out previously, robust data is seldom available, despite its value for
formulating and refining policy.[69]
Through the proposed monitoring framework, EU coordination will deliver the
evidence to MS to justify more focused and multi-sectoral approaches to HEPA
promotion. Ultimately, a ‘joint monitoring’ will help MS to save costs since it
will serve to improve investment of scarce resources. This is particularly
relevant in the current economic context.
The view that
the EU has a role to play in contributing to promoting HEPA is shared not only
by the EU institutions, existing EU level cooperation structures for sport and for
health as well as at expert level, but also by a large segment of stakeholders (e.g.
sport for all organisations or the sporting goods industry) and EU citizens.[70] By approaching HEPA promotion from a sport policy
perspective, the EU can make a real difference, boosting its effort by drawing on the huge potential of
the sport movement to reach large parts of the EU population, inter alia
through membership in a sport club. Citizens usually like sport and its
connotations are unmistakably positive. The results of
the 2010 public consultation referred to above confirm the widespread
support for EU action to promote HEPA. Asked to identity priorities for
future EU action, respondents (which included individual citizens as well as
nearly 400 stakeholder organisations, most of which were sport organisations, NGOs,
and public authorities from across the EU) were overwhelmingly in favour of an
EU role in promoting physical activity.
Figure 1: Future priorities for EU action in the field of
HEPA
Source: EU-wide public consultation (2010):
Strategic Choices for the Implementation
of the New EU Competence in the Field of Sport
2.6.        Baseline
scenario
The
continuation of current arrangements building on existing structures and tools at
MS, international and EU level - as described in sub-chapter 2.1.2 - would lead
to the following elements that would continue to work unsatisfactorily
in combating the problem described.
Firstly, regarding
advocacy power, recent intensified calls from experts worldwide and
stakeholders (e.g. ‘Designed to move’ campaign) on the policy level “to act
now” will help raise awareness on the importance of physical activity. Such initiatives
are valuable in that they point to shortcomings and help to make the case
for additional policy action. It is however highly unlikely that they alone
could lead to real change towards more effective HEPA policy making in the EU.
In addition, such initiatives are often built on an evidence base that
describes the global problem, but does not contain data covering several or all
EU MS.
Secondly, on
the lack of capacity in the MS, a continuation of current arrangements will
only marginally improve the understanding and intersectoral capacity to
develop, design and implement effective HEPA policies. In the EU context, the
conditions for cooperation in the field of sport (i.e. Council mandate for the
XG SHP) and of health (mandate of the HLG) are expected to continue also after
their current lifespan (i.e. after 2013/2014). Given
the priority of HEPA in the current EU Work Plan for Sport and considering that
the XG SHP has helped to foster the exchange of information, it is expected
that a similar Expert Group will be set up to continue work in the field of
HEPA promotion after the mandate of this group in the context of the next EU
Work Plan as of 2014. Likewise, in the field of health, the HLG has provided a
forum for engaging in coordinated activities as well as exchanging and raising
awareness of key issues among public authorities over the past several years,
and its work is likely to continue. While the achievements
of the existing structures should be recognised, the continuation of these
forms of cooperation consisting essentially of a mere exchange of best
practices, sharing of policy ideas and discussion of 'HEPA promotion' between
the MS is, however, not likely to solve the problem of ineffective national
HEPA policies and, ultimately, to increase physical activity levels in the
EU. Moreover, although nutrition and physical activity are stated core areas of
action in the Strategy on Nutrition, Obesity and Overweight-related Health
issues, the HLG combines expertise mainly in the field of nutrition[71] There
are different reasons for this, one stemming from the expertise and priorities
of those involved: many of the Ministry of Health officials participating in the
HLG are responsible for nutrition policy but not for physical activity.[72] MS specialised capacity on
physical activity would remain weak.
Thirdly, the
focused policy approach to physical activity, which forms the basis for
effective HEPA promotion, will continue to be inexistent in most MS and in the
EU without additional EU action. For instance, recent
deliberations of the Council in the form of conclusions that call for more
concerted action to promote physical activity confirm the existence of the
problem from the policy side, but do not foresee measures that are likely to
have sufficient leverage to convince many MS to reconsider their national
approaches to HEPA across sectors. There is also no reason to believe that the
political statements to which European countries have signed up in broad
international strategies and voluntary action plans[73] would suddenly become more
effective tools than in the past to lead to a stronger policy focus on HEPA in
national and EU policy making. Current arrangements are rather conducive to
continued progress in those MS that are already pursuing relatively effective
approaches to physical activity promotion. Thereby the noted discrepancies
between MS who make progress in developing and implementing effective HEPA
policies and those who do not would continue if not increase. It appears that HEPA
would very likely continue to be undervalued in national and EU policy making
and not get the recognition as a focused discipline requiring a multisectoral
policy approach. 
Fourthly,
related to the above arrangements and the lack of a focused policy is the policy
coordination at EU level and between the MS more particularly, which would
remain weak. As a consequence the development and implementation of
effective policies in the MS, such as provided for by the EU PA GL would
continue to advance at a low pace and, considering developments since 2008, would
leave out a number of MS, especially those that face the greatest challenges
with regard to their national physical activity levels. This progress, in
addition, would continue to depend on efforts by individuals in single HEPA
sectors (e.g. sport, health, transport) in view of the lack of a coordinated
and focused policy approach driven by the impetus from an EU initiative that is
designed to reach out to all relevant sectors. Ensuring the cross-sectoral
cooperation between relevant actors and Ministries in the MS, to be achieved
through the implementation of the GL, would continue to be the key challenge
for individual countries that often lack the necessary capacity – this can be
barely changed by general policy statements or discussions on the GLs'
implementation in the way it has been done until now in meetings between MS at
EU level. Without stronger political support most MS are not likely to step
up efforts across sectors.[74]
Finally, considering
the continuation of the current situation, monitoring of physical activity
aimed at achieving sound and reliable data on national HEPA levels and HEPA
policies would remain difficult if the current weaknesses of collecting,
validating and processing national physical activity data, reported by experts
and policy makers[75],
were not addressed. Further collection of information on progress in
establishing national guidelines on physical activity and related actions in
line with the EU PA GL, as it has been done by the XG SHP, would only serve as
a general overview, but could not be considered a systematic collection of data
for monitoring progress in policy development and implementation and that has
value in guiding future policy. Regarding the implementation of the 'EU
Strategy', information on nutrition, physical activity and obesity prevention
would continue to be collated and processed within the current EC/WHO
monitoring project (NOPA II) until mid-2014; this means a national coordinator
in a MS would collate the information in all fields of the 'Strategy' which
would then be made available and updated in the WHO information system (NOPA
database). Although the WHO issued concrete recommendations for the effective
monitoring of physical activity on the basis of the standardised IPAQ and GPAQ
questionnaires (referred to in sub-chapter 2.2.3), the physical activity data
so far collected for the NOPA database points to important methodological shortcomings
regarding the data received from a number of MS. In the WHO context,
independent sustainable physical activity counterparts, similar to those
existing for nutrition, are considered desirable to improve monitoring on
physical activity in the European Region. Within the current EU monitoring
arrangements, specific coordinators on physical activity that could be expected
to deliver more complete and comprehensive data in the field of physical
activity would not be established. The unsatisfactory situation of
fragmented or lacking data on HEPA (as repeatedly criticised by the expert
and the policy levels and confirmed by the WHO)[76] is therefore likely to
continue, making it difficult to track progress in individual countries
over time, compare developments between them and identify trends in the EU. Not
improving current monitoring arrangements would amount to a missed opportunity
for informed future policy decisions. 
To conclude, regarding
how the problem would evolve all things being equal, it can be assumed that
physical activity rates would continue to be unacceptably low in the EU.
Despite the initiatives in the MS as well as at EU and international levels
aimed at addressing the problem, there are currently no indications that the
general trend towards stagnating or declining physical activity levels in the
EU as a whole is about to be reversed. Instead, very high rates of physical
inactivity can be expected to continue, leading to the described economic
and social detriments. 
3.           DEFINITION
OF POLICY OBJECTIVES
The EU has been addressing HEPA through a
number of policies and instruments. It is important to note that the proposed
new initiative is not intended to fundamentally alter the course of policy, but
to reinforce a focused approach on HEPA by facilitating a more widespread,
consistent implementation of what already exists, in particular the principles
contained in the EU PA GL. The following objectives have been defined with this
in mind.
3.1.        General
objective
The general objective can be expressed as
follows:
Contribute to a healthier and more productive
society through increased levels of health-enhancing physical activity in the
EU. 
3.2.        Specific
objective
The initiative would seek to increase the
effectiveness of MS’ HEPA policies by enabling MS to develop and implement HEPA
policies based on the EU PA GL, which would help them address the main
shortcomings (lack of cross-sectoral approach, unclear objectives, insufficient
monitoring). The development of policies and their implementation would take
place at MS, rather than EU, level. Therefore, the single specific objective is
expressed as:
Ensure the EU Member States develop and
implement effective policies for HEPA by improving the uptake and
implementation of the EU PA GL.
3.3.        Operational
objectives
Operational objectives should fulfil the
specific objective and will be linked directly to underlying policy drivers and
the parameters of the future initiative. They relate to areas where the EU
could be expected to add value in light of the justification for EU action and
baseline scenario, and consist of:
(1)                   
Enhance policy co-ordination between the EU
Member States in the field of HEPA, based on a focused approach to HEPA
promotion, to improve Member States’ capacity to design and implement effective
HEPA policy.
(2)                   
Facilitate the collection of comparable and
comprehensive data on HEPA and HEPA policies in the EU Member States.
3.4.        Consistency
of objectives with EU strategic objectives
Action to promote HEPA is desirable from
the perspective of the EU as it contributes to wider EU policy objectives, in
particular those defined in the Europe 2020 Strategy – as described in sub-chapter
2.5.2. The strategy highlights that, in order to reach the overarching
objective of inclusive growth, the EU has to be able “to meet the challenge of
promoting a healthy and active ageing population to allow for social cohesion
and higher productivity”. By promoting HEPA along the EU PA GL, the EU would
address one of the key factors that can contribute significantly not only to
healthy and active ageing (i.e. with regard to older people in employment,
their social participation and independent living), but in particular also to a
healthy workforce and ultimately higher productivity.[77] 
3.5.        Coherence
of objectives with those of other policies
The proposed
initiative is also fully coherent with EU policies in a number of other fields,
in particular:
·                        
Health: The EU
Health Strategy commits the EU to tackling health inequality, and to promote
health and prevent disease throughout the lifespan by tackling key issues /
health determinants including physical activity. It notes that: “Improving the
health of children, adults of working age and older people will help create a
healthy, productive population and support healthy ageing now and in the
future.”[78]
The importance of encouraging HEPA is also emphasised in the Strategy for
Europe on Nutrition, Overweight and Obesity related Health issues.[79]
At the end of 2011, the Council expressed its commitment to “accelerate
progress on combating unhealthy lifestyle behaviours, such as (…) lack of
physical activity, leading to increased incidence of non-communicable diseases
(…).”[80]
It inter alia called on the MS and the COM to reinforce and continue action to
support healthy lifestyle behaviours, including encouraging the development of
urban and social environment policy conducive to physical activity for all. 
·                        
Transport: The EU
Action Plan for Urban Mobility[81] stresses the need to
promote integrated urban transport policies, and notes that sustainable urban
transport (including active commuting) can play a role in creating healthy
environments and contribute to reducing non-communicable diseases.
·                        
Social inclusion:
Sport and physical activity are increasingly recognised as an instrument for
social inclusion. Women and disadvantaged groups, including lower
socio-economic groups, immigrants, and people with a disability generally tend
to have lower HEPA participation rates, even though their participation has
been shown to have a potential positive impact on integration and equal
opportunities. This link has been recognised inter alia in the EU Disability
Strategy[82]
(in particular with regard to accessibility).
·                        
Research: EU
research policy[83]
includes actions to identify, develop and apply innovative approaches and “good
practices” to reduce sedentary behaviour and enhance the level of physical
activity in the population, combined with dietary or other interventions. The
relevant research, using the concept of social innovation, may cover various areas
affecting lifestyle and should identify more effective and efficient
evidence-based strategies for reducing sedentary behaviour and increasing
physical activity, as well as facilitating multi-disciplinary policy
environments and collaboration between different public and private
stakeholders, including Small and Medium Enterprises (SMEs). The aim is a
greater uptake of innovative approaches by policy makers and to make it more
appealing to citizens to choose a healthy lifestyle.
4.           POLICY
OPTIONS
In view of the
concrete objectives defined in the previous section, a range of options to
support MS in their endeavours to develop and implement effective policies for
HEPA promotion is being considered hereafter. The options have been elaborated
with a focus on their content. Regarding the policy instruments at the COM's
disposal, the implementation of these options requires either a COM Communication
or a COM proposal for a Council Recommendation. 
The options that have
been discarded are:
·                        
A complete cessation of EU policy coordination
on HEPA, since this would contradict the EU's stated wider policy goals and run
counter to the objectives of this as well as other initiatives;
·                        
A policy option that would put the main focus on
a revision of the content of the EU PA GL. The GL represent the current state
of scientific knowledge and have been confirmed again by the Council in its
conclusions on HEPA (Nov. 2012). It is suggested that adaptations to include
possible new scientific findings on HEPA promotion and to reflect possible new
developments in HEPA policies can be made in the context of the full evaluation
of the implementation of the proposed Recommendation.
·                         
To address the problems identified, a policy
option that focuses solely on the adoption of new incentive measures in the
area of HEPA, such as foreseen in the Sport Chapter of the Erasmus+ Programme,
cannot be a solution for a policy initiative either. Recent analysis[84] has shown such an option to be
relevant for the implementation of grassroots level activities, such as support
for HEPA cooperation projects involving sport organisations, rather than the
development and implementation of sport policies. Accordingly, the main
operational objective of the Sport Chapter in the proposed Erasmus+ Programme
in the field of HEPA is proposed to be support for the implementation of the EU
PA GL.[85]
Table 3:
Policy options to be assessed
   || Option || Brief description 
 A || Baseline scenario (continuation of status quo) || §   Continued policy coordination with the involvement of the Expert Group on Sport, Health and Participation (XG SHP), and the High Level Group (HLG), underpinned by the EU Physical Activity Guidelines (EU PA GL), but no new policy initiative. 
 B || Push for increased policy coordination (Tool: Commission Communication) || §   Policy document (with no mandatory authority) setting out a strategic approach for focused HEPA promotion across sectors; §   Enhanced policy coordination at EU level with the involvement of the XG SHP, and the HLG, facilitated by the COM; §   Actions to encourage MS to commit themselves to the principles embodied in the EU PA GL; §   Call on MS to report on progress in implementing the EU PA GL taking account of existing reporting tools and structures. 
 C || Push for increased policy coordination and monitoring, based on a limited set of indicators on the implementation of the EU PA GL (Tool: Proposal for a Council Recommendation) || §   Policy document with legal effect (establishing non-binding rules) recommending focused HEPA promotion across sectors; §   Enhanced policy coordination at EU level with the involvement of the XG SHP, and the HLG, facilitated by the COM; §   MS (meeting in the Council) reaffirm and commit themselves to the principles embodied in the EU PA GL; §   MS agree to monitor HEPA policy development and implementation using a limited set of high-level and aggregate indicators relating to the EU PA GL and to report back to the EU level; §   COM supports the monitoring framework and assists MS in their implementation efforts. 
 D || Push for increased policy coordination and monitoring, based on a comprehensive set of indicators covering each of the 41 EU PA GL and evaluation against targets/benchmarks. (Tool: Proposal for a Council Recommendation) || §   Policy document with legal effect (establishing non-binding rules) recommending focused HEPA promotion across sectors; §   Enhanced policy coordination at EU level with the involvement of the XG SHP, and the HLG, facilitated by the COM; §   MS (meeting in the Council) reaffirm and commit themselves to the implementation of all 41 EU PA GL; §   MS agree to monitor HEPA policy development and implementation by using a comprehensive set of quantitative and qualitative indicators relating to the EU PA GL and to report back to the EU level; §   MS agree on benchmarks and targets for the implementation of the GL; §   COM supports the monitoring framework, assists MS in their implementation efforts and evaluates MS' performances against benchmarks and in achieving targets. 
Option A (baseline scenario) would entail a continuation of the status quo, including all of the
EU policies and initiatives described under policy context (sub-chapter 2.1.2)
and baseline scenario (chapter 2.6).
Option B would introduce a renewed strategic vision for the EU towards a
focused approach to HEPA promotion across sectors and coordinated policies in
the MS in form of a policy document with no legal effect (i.e. a COM
Communication). Building on the already existing policy documents in the field
of HEPA, including the EU PA GL, such an initiative would express a renewed
political commitment to HEPA in line with the EU PA GL, and would in addition
outline key actions involving the MS, the COM and other relevant actors. Under
this option, MS would be invited a) to develop a national strategy and
corresponding action plan for promoting HEPA across sectors, in line with the
EU PA GL, and b) to regularly report progress against the action plan and
exchange best practices within relevant EU-level structures. The proposed
initiative would call for enhanced policy coordination on HEPA between MS at EU
level within relevant existing structures. The XG SHP (which is supposed to
continue under a new mandate from mid-2014) and the HLG (with regard to EU
activities in the field of nutrition, overweight and obesity-related health
issues) would remain the principal fora for this.
Options C
and D would add to this political commitment to a
focused approach on HEPA and enhanced policy coordination within relevant
structures (i.e. the XG SHP and the HLG) another element, namely provisions for
establishing a monitoring mechanism to record, measure and compare the progress
made by MS, with a view to implementing the EU PA GL. The GL contain specific
“guidelines for action” aimed at a number of sectors. The intention is that a
reaffirmation of the GL coupled with a specific mechanism to monitor their
implementation would lead to a more systematic and constructive form of
coordination and peer learning, and as a consequence, a greater focus on
effective HEPA policies at the national and sub-national levels. Principally,
an initiative under these options would invite the MS a) to develop a national
strategy and action plan for promoting HEPA across sectors, in line with the EU
PA GL; b) to monitor the implementation of the EU PA GL at national level,
based on an agreed set of indicators to measure changes in physical activity
and in HEPA policy; and c) to report back at regular intervals on progress
made. To support these activities MS would be asked to set up "national
focal points for physical activity" charged with collecting data for the
monitoring framework and with providing country-specific information on
relevant national policies and action plans.[86]
The COM would
facilitate this process in two ways: a) by providing support for the set up and
running of the monitoring mechanism (e.g. support for training of focal points,
developing a system for recording and managing the monitoring data making use
of and complementing existing initiatives, including the WHO's NOPA database[87]) and b) by supporting MS in
the development and implementation of policies consistent with the EU PA GL and
thereby enhancing MS' capacity (e.g. support for capacity building provided by
HEPA experts). Options C and D would apply to all MS; those who have made less
progress addressing physical inactivity can learn from the progress made in
other MS that have had more success in raising the physical activity levels of
their citizens. Support would be targeted first and foremost at MS most in need,
the choice of which would be based on a combination of HEPA expert views,
information stemming from prevalence data, analysis of existing policies (incl.
further work on "HEPA PAT") and the willingness of MS to develop and
implement more effective HEPA policies.[88]
The HEPA
monitoring framework would thereby develop further existing forms of monitoring
and data collection in this field currently established under the Strategy for Europe
on Nutrition, Overweight and Obesity-related health issues with the involvement
of WHO Europe. It is expected that WHO Europe would prepare country-specific
overviews on HEPA (‘country snapshots’) and analysis about HEPA developments
and trends, building on and improving the existing NOPA database. The snapshots
would be submitted to the COM and, together with other relevant information
about HEPA policy development and implementation provided by the national PA
focal points to be established under the strengthened mechanism, form the basis
for discussion at the relevant EU level fora (e.g. XG SHP). All these elements would
form the basis for periodic reports from the COM to the XG SHP and the HLG
respectively to provide updates on progress and demonstrate the initiative’s
contribution to the EU's strategic approaches and activities in the field of
physical activity and healthy lifestyles more generally. The diagram in Annex
IV illustrates the main actions and activities of the monitoring framework.
All these
elements, i.e. endorsement of the EU PA GL, recommended value-adding activities
in the MS (e.g. the adoption of a national strategy and a related action plan
responding to countries' specific needs and conditions) and the participation
in the monitoring mechanism would become part of the non-binding document
stressing the need for more policy coordination, which is proposed to take the
form of a Council Recommendation[89],
i.e. an instrument with legal effect establishing non-binding rules. 
The key difference between Options C and D
relate to the comprehensiveness of the monitoring mechanism: 
·                        
Option C would
focus on a limited set of indicators related to high-level information and more
general aspects of the EU PA GL. Annex III gives an overview of the exact
nature of the 23 indicators which are proposed to be included in such a
monitoring mechanism.
·                        
Option D would
provide a more comprehensive mechanism for monitoring the implementation of the
EU PA GL, as well as for the setting of benchmarks and targets against which
MS’ performance would be evaluated. In addition, this option would entail a
larger set of both quantitative and qualitative indicators, covering each of
the 41 EU PA GL in detail.
For options C and D all MS are supposed to
participate in the monitoring framework and make the necessary structural
arrangements at national level (e.g. set up physical activity focal point). For
a country like e.g. FI that already has a well-established cross-sectoral
approach to HEPA policy making the participation in monitoring is expected to
be a more comfortable and undemanding exercise as opposed to MS where effective
HEPA promotion does not yet exist.
5.           ANALYSIS
OF IMPACTS AND OF EFFECTIVENESS
This chapter analyses the types of impacts
that could be expected from a new EU initiative in the field of HEPA, i.e. direct
social and indirect (but significant) economic benefits, in addition to
environmental benefits from increased reliance on active forms of transport
(cycling and walking). Impacts are quantified where possible and indications of
their scale are provided.[90]
These are similar for all policy options, but are likely to vary in scale as a
function of each option’s effectiveness. Given that the detailed assessment of
effectiveness of policy options (i.e. their outputs and outcomes) is a
prerequisite for assessing the impacts of the initiative (options), it is
merged with this chapter on assessment of impacts. In doing so, the outcomes of
policy options are defined in terms of more effective national HEPA promotion
policies (specific objective) while the impacts per option are defined in terms
of physical activity levels (general objective) and summarised in chapter 5.5.
In all cases, the effectiveness, precise benefits and costs of the initiative
will depend on the policy choices of individual MS and the interventions
stemming from them. Improvements in physical activity levels that could be
expected from an EU initiative are therefore likely to substantially differ
across MS and regions.
5.1.        Social
impacts 
The
benefits of increased physical activity
The social
benefits would stem from increased HEPA among Europeans as a result of more
effective HEPA policy in the EU MS and implementation of the EU PA GL, provided
that MS are willing to develop and invest in such policies. Although the EU PA
GL cover a wide range of policy areas, their overarching goal is that, through
the development and implementation of national strategies, the MS achieve the
WHO-recommended minimum of at least 150 minutes moderate-intensity physical
activity weekly, or 75 minutes of vigorous-intensity physical activity, or an
equivalent combination of moderate- and vigorous intensity activity. 
The myriad benefits of meeting physical
activity recommendations as well as the low rates of physical activity in the
EU have been well documented and were described inter alia in the problem
analysis section and in Annex II. Briefly, engaging in the recommended amount
of physical activity has above all beneficial health effects, addressing many
chronic diseases and health problems, including but not limited to those linked
to obesity. This includes significantly reduced risks of eight serious health
conditions: heart disease, stroke, overweight and obesity, type 2 diabetes, colon
cancer, breast cancer, falls in older people, and depression.[91]
The upshot of
this is that people who do not undergo enough physical activity suffer from a 20-30%
increased risk of all-cause mortality compared with those engaging in at
least the recommended 150 minutes weekly of moderate intensity physical
activity.[92] Increased rates of physical activity among Europeans would result
in a commensurate drop in the number of people suffering from this increased
mortality risk. 
Obviously, the
detrimental effects of high levels of physical inactivity are borne first and
foremost by those individuals who do not engage in sufficient HEPA. These
negative impacts are more pronounced among specific countries and regions, and
specific groups of people within them, in particular specific-at risk groups
such as the elderly or socially disadvantaged people – as confirmed by many
studies, also referred to in Annex II.[93]
Thus, the initiative would be expected to make some inroads into reducing
health disparities, improving social inclusion and protection. It would also
contribute to ensuring a high level of human health protection (Article 35 of
the EU Charter of Fundamental Rights) and to advancing equal opportunities of
at-risk-groups, thereby promoting indirectly for instance the principle of
non-discrimination (Article 21) and equality between women and men (Article
23). Furthermore, by providing initiatives at schools, for the elderly and
"at-risk" or those from low socio-economic groups, the EU PA GL will
undoubtedly have a direct or indirect positive effect on groups of society
protected by the Charter: children (Article 24), the elderly (Article 25) and
persons with disabilities (Article 26). When promoting or implementing such
policies, the best interests of the child, the rights of the elderly to sustain
an independent life and to participate in social life and the rights of persons
with disabilities to benefit from measures to help them lead an integrated life
in the community will come into play.
Given the
manifold factors that play a role in life expectancy and similar statistics, it
is not possible to attribute the differences in life expectancy directly between
high- and low-physical activity countries to the level of physical activity.[94] Nonetheless, physical activity
is certainly an important contributing factor for all of the reasons described
above and in the problem definition section. Recent studies in the US associate
leisure-time physical activity with longer life expectancy and confirm that
even modest amounts of physical activity can add years to people's life (even
if it does not result in weight loss)[95].
A simplified calculation shows that in the EU, levels of physical activity
are positively correlated with life expectancy, meaning that those countries
with higher levels of physical activity tend to have a higher life expectancy.[96] 
The extent
to which effective policy can lead to increased physical activity levels
Always bearing
in mind that improvements are likely to substantially differ across the EU, in
order to estimate how policies to promote physical activity can impact HEPA
levels over the medium and long term, it is worth looking at an example.
Finland identified low physical activity levels as an issue to be addressed
earlier than most MS and has continued to both prioritise HEPA and monitor
comparable yearly data on physical activity levels since the early 1980s. It is
therefore an excellent example of a country where the medium- and long-term results
of effective HEPA policy can be measured. Undoubtedly the evolution of HEPA
rates over time in Finland has been affected by a range of factors other than
policies specifically aimed at increasing HEPA (e.g. individual behaviour,
socio-demographic factors, seasonality). Nonetheless it is instructive to
consider the change in HEPA rates in Finland which, as shown in the chart
below, amount to a sustained increase of about 1% increase per year over a
period of 27 years.
Figure 2: Evolution of the proportion of Finns engaging in
twice per week leisure time physical activity
Source: Health
behaviour among the adult population, Finnish National Public Health Institute[97]
Canada, which is
outside the EU but socioeconomically and culturally similar to many EU
countries, is another of the few examples of countries that have prioritised
physical activity promotion already for a number of decades. It has achieved
similar increases, with a 21% gain in leisure time physical activity
participation from 1981-2002.[98]
Such change over time is also considered feasible and desirable by the WHO,
which in November 2012 recommended that individual countries should set a
target of a 10% reduction in the prevalence of insufficient physical activity
by 2025 (see section 2.1.2), with the magnitude of change that can be expected
by decisive action in the order of about a 1% change per year.[99]
There are good practice examples
illustrating how targeted policy interventions focusing on specific-at risk
groups, for instance women in disadvantaged communities or senior citizens,
have led to increased physical activity levels. For instance, good practices
have been or are currently being collected as part of transnational cooperation
projects financed under the Preparatory Actions in the field of sport, e.g. in
2009 (call focusing on ‘gender’) or 2012 (call focusing on ‘physical activity
contributing to active ageing’) or under the Health programme 2008-2013. 
5.2.        Economic
impacts
Economic benefits
Enhanced
health and well-being can be expected to lead to significant further benefits
of an economic nature, as health care costs go down and the amount of
economic output forgone due to illness and morbidity, sick leave and pre-mature
death decreases. Studies have attempted to monetise the costs of these factors
due to lacking physical activity. One study carried out for the British
government identified costs to England of just over €3bn per year, or €63 per
inhabitant[100].
Through a simplified analysis that extrapolates across the EU the same cost per
inhabitant, the lack of physical activity in the EU can be calculated as costing
over €31bn per year.[101]
With regard to
these costs of physical inactivity, improved HEPA promotion policies if developed
and implemented in line with the planned initiative would be expected to
increase the proportion of EU citizens meeting physical activity
recommendations, gradually chipping away at the cost of physical inactivity
over time. Under an optimistic assumption based on scenarios in line with the
Finnish and Canadian examples, and considering that investments would be
required at different levels in the MS, effective HEPA policy can be expected
to increase the proportion of citizens meeting recommended physical activity
thresholds by up to about 1% per year. Taking the latest Eurobarometer figures
from 2010 as a starting point, implementing effective HEPA policy could
theoretically see about 65% of Europeans meeting physical activity
recommendations in 25 years, with the cost of inadequate amounts of
physical activity gradually heading downwards.
Figure 3: Estimated economic savings through rising levels
of physical activity
Source: TEP based on Eurostat data (http://ec.europa.eu/sport/library/documents/d/ebs_334_en.pdf)
and British government report ‘Game Plan"
The scenario
as depicted is simplified and depends on the capacity and willingness of the MS
to prioritise and implement effective HEPA policy over the long term. Finland
and Canada have achieved increases in HEPA levels of about 1% per year over
reasonably long periods. 1% per year also seems realistic in the light of the abovementioned
global target of a 10% relative reduction in prevalence of insufficient
physical activity by 2025: EU MS, as members of the WHO, are part of the works
concluded on the global monitoring framework (see fn 99) and the setting of
these targets that apply to all countries, including low- and middle income
countries. 
Over time,
maintaining a momentum of 1% p.a. would gradually become more difficult,
eventually reaching a point of saturation where further improvements would be
prohibitively expensive. Today the MS and the EU overall are far away from this
point and the projected economic benefits would be huge, in terms of
avoiding the costs of physical inactivity (health care savings and increased
productivity), adding up to nearly €7bn after 5 years, €22bn over 10 years and
€63bn over 20 years (taking, as an approximation, the costs calculated for
England as a basis). This would in turn justify requisitely large expenditure
on policies and initiatives to boost HEPA levels, as shown in the table
hereafter. 
Table 4: Economic value of
increased HEPA levels[102]
 Year || % of Europeans meeting PA recs* || Annual savings due to increased HEPA levels || Cumulative economic value of increased HEPA 
 2017 || 45% || €2.5bn || €6.7bn 
 2022 || 50% || €5.1bn || €21.5bn 
 2032 || 60% || €10.3bn || €63.3bn 
 2037 || 65% || €12.9bn || €63.4bn 
*figures based on
the optimistic assumption of a 1% increase compared to 2010 levels of the
Eurobarometer survey 
According to
the table, under a best-case scenario, EU-wide benefits of €6.7bn would
result from initiatives to increase HEPA rates by about 1% per year over the
next 5 years. These are approximations; the exact results obviously have to be
validated.
Economic costs
- Impacts on Member States' budgets:
MS would have
to bear costs relating to the implementation of HEPA policies following the new
initiative and administrative costs stemming from the reporting requirements to
the EU level. In addition, under options C and D, they would have to appoint a
"national physical activity coordinator" (one per MS).
While the
benefits of increased HEPA are manifold, implementing policies that encourage
Europeans to take part in more HEPA entail a variety of (substantial)
implementation costs. Depending on the specific policy in question, these
range from the infrastructure costs of constructing, say, cycle lanes or
leisure time infrastructure, to training teachers in physical activity
promotion, to providing subsidies to employers that create a physical-activity
friendly environment or encourage active commuting, to collecting data on
HEPA-related topics so that policy can be continuously improved. The costs of
HEPA promotion are not only spread around government ministries and
authorities, but various NGOs and the private sector as well. Moreover, the
different institutional and administrative structures, and diverse cultures of
the EU MS ensure that no two MS would take the same approach to
(effective) HEPA policy, meaning that costs would be highly variable. The
benefits of increased physical activity largely depend on MS' willingness and
ability to put money into HEPA promotion policies, with the consequence that MS
would continue to evolve at different speeds. Moreover, a country such as
Finland that already has monitoring in place would have to invest relatively
less than a MS that has no strategic policy implementation in the field of
HEPA.[103]
The fact that limited information is currently made available in the MS on the
budgets invested into HEPA promotion across policies makes it impossible to
make an exact estimate on the investments to be made. The enhancement of
monitoring provisions, as proposed by the planned initiative, should aim at
addressing this shortcoming and help in adapting national policies on HEPA promotion,
in particular in those MS that have been less successful in raising the
physical activity levels of their citizens.
The envisaged
policy coordination at EU level coupled with support for capacity building and
monitoring (options C and D) would help the MS to target investments to the
measures that are known to deliver the highest return, based on best practices.
Thus the impacts on respective MS' budgets need to be quantified carefully as
an early step in HEPA policy implementation.
Today,
spending on HEPA is not recorded comprehensively across the EU. This is
exacerbated by the fact that HEPA is by nature cross-sectoral, that many
policies are tangentially related to HEPA and that policies which promote HEPA
do not always (or often) include HEPA promotion as a primary objective. This
makes calculating the budget currently allocated to HEPA fraught, especially
for the purposes of making comparisons between countries. Even the HEPA PAT,
which for seven countries contains the most in depth information available on
physical activity promotion policies, cannot provide any estimate of
absolute expenditure on HEPA in any individual EU country.[104] 
It is also
worth noting that MS will be responsible for the main budgetary considerations
related to the initiative, in line with national circumstances and political
priorities. Thus, while the effectiveness of the initiative will depend on
substantial funds being allocated to HEPA promotion, the majority of the costs
will be determined by MS themselves.[105]

The administrative
costs of options B, C and D can be calculated, albeit only as a mere order
of magnitude, by applying the standard cost model. This uses rough
estimates for the time (in terms of FTEs) that would be required of MS
administrations to estimate the administrative burden (based on average EU
tariff per hour[106]).
The calculation assumes a) that the first year would require more resources
than subsequent years, as relevant staff familiarise themselves with the
monitoring mechanism; and that b) relatively junior staff could be used to
collect and manage the data. For option B, some limited reporting, however no
monitoring based on indicators, would be foreseen and would require staff time.
Table 5: Administrative costs[107]
   || Member State FTEs || Unit cost || Admin. burden per MS 
 Year 1 || Year 2+ || Year 1 || Year 2+ 
 Option A || - || - || - || - || - 
 Option B || 0.06 || 0.04 || € 56,425.60 / year || € 3,655 || € 2,244 
 Option C || 0.2 || 0.1 || € 56,425.60 / year || € 11,285 || € 5,643 
 Option D || 0.4 || 0.2 || € 56,425.60 / year || € 22,570 || € 11,285 
- Impacts on the EU budget:
A smaller
proportion of the costs emanating from the implementation of the new initiative
would fall on the EU budget. Apart from costs relating to the organisation by
the COM of Expert Group meetings at EU level (e.g. three meetings per year of
the XG SHP) as provided for under all options, costs to the EU budget would
mainly stem from the costs of setting up and managing the monitoring
mechanism and support to MS (capacity building). They would therefore vary
depending on the option chosen, i.e. option C or D, which are the only options
that propose establishing such a mechanism. Based on COM’s experience of
funding the NOPA database project and following expert judgement, the COM would
bear some financial burden in identifying, coordinating and training national
focal points, maintaining a centralised data base and producing periodic reports
on progress. For option C, this could be expected to total approximately EUR 2,680,000
for the entire MFF period (2014-2020), with relatively higher costs for the
first two years of the initiative and reduced costs in the following years,
once the mechanism is fully operational. These costs would be higher for option
D and would amount to an estimated EUR 3,369,000, given the more complex
monitoring arrangements involving a higher number of indicators, setting
benchmarks and targets and requiring additional evaluations. It is proposed
that these costs would be covered by the Sport Chapter of the proposed Erasmus+
Programme.[108]
Costs for meetings of the Expert Group would be covered by the general budget
(Global envelope). The table hereafter provides a summary of the costs to the
EU budget for 2014-2020. A further breakdown of these costs can be found in
Annex V.[109]
Table 6: Impact on EU budget 
   || Total costs to the EU budget for the period 2014-2020 
 3 meetings / year (19 in total as of mid-2014)  at EU level (28 MS) || Support for PA monitoring framework and PA policy dev. + implementation ||   Total per option 
 Option A || EUR 532,000 || - || EUR 510,000 
 Option B || EUR 532,000 || - || EUR 510,000 
 Option C || EUR 532,000 || EUR 2,680,000 || EUR 3,212,000 
 Option D || EUR 532,000 || EUR 3,369,000 || EUR 3,910,000 
5.3.        Environmental
impacts
Policies aimed
at implementing the section of the EU PA GL that addresses transport,
environment, urban planning and public safety (GL 25-32) could also result in significant
environmental benefits and thereby contribute to a high level of
environmental protection, enshrined in Article 37 of the EU Charter of
Fundamental Rights. The extent of these benefits is dependent on several
factors, namely whether MS, depending on their national priorities, prioritise
this section of the Guidelines and whether it leads large numbers of people to
switch from passive (i.e. motorised) to active forms of transport. While it is
extremely difficult to make accurate predictions for either of these factors,
recent scientific research can provide some insight into what can be considered
the optimum scenario in terms of the environmental benefits of the initiative. 
A recent study sought to predict the extent
to which a reorientation of transport policy towards active transport in London
would affect carbon emissions over 20 years in comparison with an evolution of
the baseline.[110]
Assuming a transition towards the cycling levels of Amsterdam, Copenhagen and
other European cities, the study calculated that the per person transport CO2
emissions would be 62% lower under the sustainable transport scenario, at
0.46 tonnes per year, than under the continuation of the baseline scenario, at
1.17 tonnes. While the specificities of London and the small scale of the study
preclude EU-level extrapolations, the study is notable for demonstrating the sheer
scale of potential environmental benefits of active transport policies.
Increases in active transport of the magnitude described in the study would
require significant political and financial investment over the long term and
would doubtless require cooperation across the policy spectrum. It is not
expected that, on its own, the subject of this IA would result in such change,
but it could contribute to a wider policy shift.
5.4.        Analysis
of effectiveness
The effectiveness of the four options
relies on (voluntary) action by the MS. However, the options vary in the extent
to which the EU calls for specific actions and / or policies and they are
closely linked to the instrument chosen to implement the initiative. [111]
5.4.1.     Option
A: baseline scenario
This option
would be likely to see continued progress in those MS already pursuing
relatively effective approaches to physical activity promotion. Likewise, these
MS would continue to make some progress on implementing the EU PA GL. No
additional action would be taken at EU level to encourage the uptake of the GL
in other MS, but possibly some may seek 'inspiration' from the published text
of the GL for policy formulation, as has been the case in recent years in Cyprus,
Poland, Hungary, Slovakia and Spain.[112]
Even in these countries, however, the small amount of available evidence
indicates that HEPA rates are not evolving favourably, which suggests that
stronger action is needed.[113]
Under this option, despite existing actions, there would be little movement
towards the achievement of the first operational objective, which relies on
co-ordinated efforts between countries, and very limited or no progress in
improving HEPA data (second operational objective). Thus, overall, the specific
objective would only be achieved to a small extent. For the EU as a whole
physical activity rates would be likely to continue to stagnate or even fall,
carrying with it the economic and social detriments highlighted in the problem
analysis.
Table 7: Effectiveness Option
A
 Option A || Effectiveness 
 Specific objective: effective HEPA policy based on EU PA GL || 0 
 Operational objective 1: policy coordination || 0 
 Operational objective 2: HEPA data || 0 
Details on operational objectives:
–                        
1) Enhance policy co-ordination between MS at EU
level on HEPA
There are two main existing fora for policy
co-ordination between the MS: the XG SHP, where members act in an official
capacity, and which has secured the participation of nearly all MS, and the HLG,
where all MS are represented. However, for various reasons, the continuation of
these fora in their existing format is unlikely to result in substantially
enhanced policy co-ordination on HEPA:
·                        
The XG SHP, without strong political support
it is unlikely to have sufficient leverage on its own to convince many MS
to reconsider their national approaches to HEPA or to considerably step up
efforts across sectors beyond sport – as confirmed by XG members meeting in
2012.
·                        
The HLG, for reasons referred to in the problem
section, has so far placed stronger emphasis on nutrition and food
reformulation than promoting physical activity. A major shift towards a
strong focus on physical activity in the continued activities of this group
therefore seems unlikely.[114]
–                        
2) Facilitate the collection of data on HEPA and
HEPA policies in the EU MS
As described
in the section on the problem analysis, current provisions for monitoring and
evaluation of HEPA and HEPA policies are insufficient in the majority of MS.
This is strongly linked to another problem identified, i.e. the lack of
cross-sectoral co-ordination that leads various actors to collect similar but
incomparable data, and has resulted in the availability of non-comparable and
fragmented data. Existing initiatives, such as the NOPA database project, offer
insight into HEPA 'policies' and monitoring methods in use in different
countries, but shed little light on the implementation or impacts of those
policies. While work is on-going on the side of the WHO to improve the NOPA
database, it will not be able to address the fact that national physical
activity data submitted within the current monitoring arrangements is of
insufficient quality or sometimes it is simply not provided.[115]
5.4.2.     Option
B: Push for increased policy co-ordination
A new
strategic focus at EU level on the importance of HEPA, including an outline of
concrete actions aimed at the implementation of the EU PA GL, could, despite
the lack of prescriptive content, result in some improvements to MS policies. Political
attention for the EU PA GL has been rather low up to this point, partly due to
their being published before the EU had an explicit competence for sport. This
is likely to have acted as a brake on the extent to which the GL have been
publicised, viewed as legitimate[116]
and, ultimately, implemented across sectors. Therefore, an
initiative that introduces a new strategic and focused approach to HEPA with
the EU PA GL building the cornerstone, would add political clout to the GL,
potentially leading to more thorough implementation. More political weight for
the GL would provide the many actors interested in promoting HEPA policy[117], incl. sport organisations,
NGOs, etc., with a potentially powerful tool for persuading funders and
decision makers to further prioritise HEPA and enact policies / programmes
in line with the GL.
However, this
option would also entail limitations to the achievement of the specific
objective. Primarily, a strategic focus alone would not provide a strong
incentive to act to those MS which currently lack the capacity and / or
infrastructure to adopt effective HEPA policy. Judging from the abovementioned
implementation report, eleven MS still have not reported any progress in
implementing the GL. Of these, the vast majority are eastern and southern
European countries that are particularly prone to low levels of physical
activity and where current trends are most alarming.
Under this
option, progress as compared to the baseline would therefore mostly stem from
enhancing policy co-ordination and improving the implementation of the EU PA
GL, albeit to a limited extent (first operational objective). However, this
option would do little to address the collection of comprehensive data (second
operational objective), since this would necessitate stronger political and
co-ordination efforts. Thus, the overall effectiveness of this option, in terms
of the policy objectives and benefits described above, would be relatively
low.
Table 8: Effectiveness Option
B
 Option B || Effectiveness 
 Specific objective: effective HEPA policy based on EU PA GL || + 
 Operational objective 1: policy coordination || + 
 Operational objective 2: HEPA data || 0 
Details on operational objectives:
–                        
1): Enhance policy co-ordination between MS at
EU level on HEPA
As pointed out in the section on the
baseline scenario and as explained in Annex I, the formal structures for policy
co-ordination, i.e. the XG and the HLG, have already gone some way to
addressing this objective.
However, the
ability of the XG SHP and the HLG to coordinate policy successfully is
inextricably linked to the importance bestowed on HEPA at political level. As
noted under Option A above, without a strong political commitment the XG would
be unable to realise its full potential, and it is currently not being realised
through the HLG. With the weight of a new strategic focused approach of the EU
on HEPA, based on the EU PA GL, setting out concrete actions for the MS and the
COM and involving regular reporting to the EU level, members of the XG will be better
equipped to promote HEPA initiatives and to secure adequate resources within
national administrations for their implementation and evaluation. This is
especially important given the cross-sectoral nature of HEPA – while physical
activity promotion may already have traction within the lead Ministry
responsible for HEPA promotion (often health or sport), the strategic
orientation at EU level and a corresponding call for cross-sectoral actions
would help the lead Ministry spur action more widely. With regard to the tool
chosen under this option (Communication) provisions for progress reporting to
the EU level would be proposed, but would remain largely voluntarily without
any prescriptive effect. This could potentially weaken the effective
enhancement of policy coordination.
–                        
2) Facilitate the collection of data on HEPA and
HEPA policies in the EU MS
In comparison
to the baseline scenario, MS would be invited to regularly report to the EU
level on national progress in implementing the EU PA GL. This option does not
propose to put into place any new structures for monitoring and evaluation
based on jointly agreed indicators, leaving the onus for monitoring and
evaluation of HEPA policies completely with the MS. However, the existing
initiatives (e.g. NOPA database, the HEPA PAT) have, for various reasons (as
pointed out in the baseline scenario and problem definition sections), not been
able to provide adequate data. Significant improvements on the availability
of HEPA data are thus unlikely.
5.4.3.     Option
C: Push for increased policy co-ordination and monitoring, based on key
elements of the EU Physical Activity Guidelines
A policy
document with legal effect would be expected to add considerable weight to HEPA
promotion in general and the EU PA GL in particular. A Council Recommendation,
committing the whole Council, is more likely than e.g. a COM Communication
(option B) or Council conclusions to improve the uptake and implementation of
the GL across the relevant sectors (specific objective) and to provide for
policy coordination engaging the MS and, ultimately, helping them to adopt
effective HEPA policies. In addition, recommending rules for monitoring based
on jointly agreed indicators would have a strong potential to drive MS policy,
providing a framework for implementing the GL and recording progress.[118] The focus on high-level,
quantitative and aggregate indicators would help concentrate minds on the key
aspects of HEPA promotion while avoiding extensively costly data
collection.[119]
This option would contribute significantly to both operational objectives
while allowing MS to prioritise effectively. The key difference with option B
is the inclusion of a monitoring mechanism, which makes it very likely that the
effectiveness of this option would be significantly greater, especially but not
limited to progress towards the second operational objective. However, this option
would entail a minor drawback. While ensuring progress on all GL themes,
the limited set of indicators represents a pragmatic choice that is unlikely to
promote MS action on each of the GL at an individual level. 
Table 9: Effectiveness Option
C
 Option C || Effectiveness 
 Specific objective: effective HEPA policy based on EU PA GL || ++/+++ 
 Operational objective 1: policy coordination || +++ 
 Operational objective 2: HEPA data || ++/+++ 
Details on operational objectives:
–                        
1): Enhance policy co-ordination between MS at
EU level on HEPA
This option would build on the scenario
described under option B, adding political momentum to the co-ordination
already being carried out under the auspices of the XG and the HLG, but would
allow for a greater level of effectiveness due to the inclusion of a monitoring
mechanism and standardised set of indicators. These would be expected to drive
MS policy, provide an incentive for action and thereby increase the usefulness
of existing co-ordination fora. Apart from the sharing of information and
good practice, through EU level coordination based on joint monitoring, MS
would be able to discuss and compare policy approaches based on improved
evidence. In combination with the targeted support for capacity building this
should enable MS to develop and implement more effective policies.
This argument
is strengthened by feedback from relevant stakeholders. A large number of MS
expressed support for a monitoring mechanism, agreeing that it would help MS
learn from the experiences of other countries. It was explained that, while an
environment for peer learning is already in place (inter alia through the XG
SHP), the lack of comparative evidence renders the taking of policy choices
based on these meetings problematic.[120]
MS and stakeholders have also emphasised that the monitoring mechanism would
ensure regular cooperation between MS, enhancing their ability to
prioritise HEPA promotion and develop more effective policies. The existence of
a monitoring mechanism implemented through a Council Recommendation would
provide the political influence needed to boost cooperation among the sectors
concerned.[121]
The choice of this instrument would give the leverage and political buying-in
that is lacking today. Its implementation would ensure the involvement and
political investment of the MS in the new initiative, laying the foundation for
policies that would be developed and implemented mostly by individual
Ministries.
–                        
2) Facilitate the collection of data on HEPA and
HEPA policies in the EU MS
This option, in addition to the arguments
outlined under operational objective 1, would make a significant contribution
to this objective too, leading to systematic and standardised collection of
data on HEPA rates and HEPA policies across the EU. A centralised mechanism
for storing and managing the data would ensure that it is largely comparable
both between countries and over time, allowing the results to feed into
decision making.[122]

However, given
the voluntary nature of the initiative, its effectiveness depends on MS’
willingness to participate in it. While, albeit limited, EU support is
foreseen to build capacity for this process, the MS will be responsible for the
data collection and for part of the reporting. This in turn hinges on ensuring
that the costs of participating are considered feasible and reasonable by MS
administrations. This option therefore calls for a limited set of (high-level
and aggregate) indicators, developed by HEPA experts on the basis of feedback
from MS representatives (i.e. by the XG SHP, Sport Directors and members of the
HLG). This option would result in a significant improvement on the current
provision of data; only in a few areas, notably relating to qualitative
information and individual GL, potentially useful information is likely to be
left out in the monitoring process.
5.4.4.     Option
D: Push for increased policy co-ordination and monitoring, based on
implementing all 41 EU Physical Activity Guidelines
Like for
option C, an official endorsement by the Council would add political legitimacy
and weight to the GL and thereby has the potential to greatly improve the
current situation by leading to growing involvement of actors and an
increasing number of actions in sectors covered by the EU PA GL (specific
objective). Recommended rules for a comprehensive monitoring scheme based on
the GL would have a strong potential to drive MS policy, providing a framework
for implementing the GL and recording progress. This more complex monitoring
framework than under option C could result in a more complete uptake of the GL
and in more comprehensive data. This option as compared to the baseline would
be expected to make progress towards both operational objectives, and thereby the
specific objective. However, retrieving the data to comply with the more
comprehensive set of qualitative and quantitative indicators will require additional
efforts, including possible additional investment. In addition, benchmarks
and targets would require substantially more political will from the MS.
Some MS may be reluctant to agree on monitoring and reporting
arrangements of that type because of a perceived lack of authority.[123] Moreover, given that the
initiative would be voluntary, these difficulties could ultimately translate
into a lack of participation (see chapter on feasibility and table 12 below).
Table 10: Effectiveness Option
D
 Option D || Effectiveness 
 Specific objective: effective HEPA policy based on EU PA GL || ++/+++ 
 Operational objective 1: policy coordination || ++ 
 Operational objective 2: HEPA data || ++/+++ 
Details on operational objectives:
–                        
1) Enhance policy co-ordination between MS at EU
level on HEPA
This option
would provide a framework for sustained political momentum, peer learning
and sharing of experiences through the existing XG SHP and HLG very similar
to that described under option C. The reporting on specific targets would
require an additional level of political buy-in and willingness to
engage in benchmarking among MS. Provided that MS commit to this, policy
coordination could be greatly enhanced, in particular in the longer run. However,
if MS were to remain reluctant, benchmarks and targets could potentially
undermine the usefulness of the XG as a forum for exchange and the open and
free-flowing debate as expected under option C.
–                        
2) Facilitate the collection of data on HEPA and
HEPA policies in the EU MS
It is in this area that this option could
have the potential to contribute most effectively. Collecting data across a
comprehensive set of quantitative and qualitative indicators, in addition to
targets and benchmarks, would result in the collection of holistic sets of
data, allowing for analysis on a wide variety of relevant topics over time
and across countries. However, the important drawback here would be that many
of the data are not yet recorded at national level, which would require more
time and investment to collect them.[124]
5.5.        Analysis
of impacts per option
Due to the varying effectiveness of the four options, the scale of
the impacts of each option is expected to differ. The table on the next page
provides a summary of the expected impacts of each of the options in comparison
with the baseline scenario. The outputs and outcomes rows offer a
preliminary description of the short- and medium-term results of the new
initiative and are described in more depth in chapter 5.4 above. The impacts
row refers to higher-level change in terms of the expected social, economic and
environmental impacts. The estimates are necessarily based on assumptions about
MS implementation of what is essentially a non-binding EU initiative, and thus
any figures provided should be interpreted as an order of magnitude of the potential
impacts and an indication of scale.
   || Option A (Baseline scenario) || Option B (Push for increased policy coordination) || Option C (Push for increased policy coordination and monitoring, based on a limited set of indicators) || Option D (Push for increased policy coordination and monitoring, based on a comprehensive set of indicators and evaluation against targets) 
 Outputs || §   Continued policy co-ordination and promotion of EU PA GL under existing structures at EU level. §   Continued work on physical activity through EU-supported initiatives and projects. §   Continued provision of fragmented data || §   Minimally enhanced policy co-ordination and promotion of EU PA GL under existing structures at EU level. §   Continued work on physical activity through EU-supported initiatives and projects within a new strategic EU approach to HEPA. §   Continued provision of fragmented data || §   Significantly enhanced policy co-ordination and promotion of EU PA GL under existing structures at EU level. §   Provision of accurate and comparable monitoring data against limited set of physical activity and policy indicators. || §   Potential for strongly enhanced policy-coordination and promotion of EU PA GL under existing structures, but risk of lack of participation. §   Potential for provision of comprehensive monitoring data against a set of qualitative and quantitative indicators + reporting on benchmarks and targets. 
 Outcomes || §   Gradually improving physical activity policies and uptake of (principles of) EU PA GL in a limited number of MS, but un-changing policies in most others. || §   Gradually improving physical activity policies and uptake of (principles of) EU PA GL in a limited but larger number of MS than under option A, but un-changing policies in many others. || §   Significantly improved physical activity policies and uptake of main themes of EU AP GL in the majority of MS. || §   Significantly improved physical activity policies and uptake of EU PA GL in some MS (but risk of many MS not implementing the initiative). 
 Impacts 
 Social || §   Stagnant or falling physical activity levels in most countries and persistence of social detriments of insufficient physical activity. || §   Small improvements in physical activity levels in some MS, but stagnant or falling levels in many others leading to only a slight reduction in social detriments of insufficient physical activity. || §   Physical activity levels increase at up to 1% / year leading to a significant reduction in social detriments of physical inactivity. || §   Physical activity levels increase at up to 1% / year (but risk of MS not implementing the initiative) potentially leading to significant reduction in social detriments of physical inactivity. 
 Economic (Annex V provides a detailed assessment of costs to the EU and administrative costs in the MS) || §   Persistence of costs of insufficient physical activity (estimated at €31bn / year) || §   Slight reduction in economic costs of physical inactivity and some economic benefits but significantly less than €6.7bn over five years that would be foreseen from effective policy. §   Some (difficult to quantify) costs to MS that dedicate resources to improving physical activity. || §   Significant reduction in economic costs of physical inactivity. §   Economic benefits of up to €6.7bn over five years. §   Some (difficult to quantify) costs to MS that dedicate increased resources to improving physical activity. || §   Significant reduction in economic costs of physical inactivity, but only in the MS implementing the initiative §   Significant (but difficult to quantify) economic benefits in the MS implementing the initiative. §   Some (difficult to quantify) costs to MS that dedicate increased resources to improving physical activity. 
 Environmental || §   Some benefits in MS that improve physical activity policy with regard to active transport. || §   Limited but notable benefits in MS that improve physical activity policy with regard to active transport. || §   Potentially significant benefits in MS that improve physical activity policy with regard to active transport. || §   Potentially significant benefits in MS that improve physical activity policy with regard to active transport. 
Table 11: Analysis of impacts
per option
6.           COMPARISON
OF THE OPTIONS 
This section compares the different options
based on their likely effectiveness, efficiency, coherence with overarching EU
policy objectives and feasibility of implementation and sustainability.
6.1.        Effectiveness
The analysis of the effectiveness of the
options was made when analysing the impacts of the initiative. While all of the
options could be expected to achieve some progress towards the specific and the
operational objectives set out in section 3, the degree of success each option
could be expected to attain varies. If compared to options C and D, the less
prescriptive provisions for progress reporting would weaken the coordination
potential of option B. The analysis shows a similar level of effectiveness of
options C and D, and comes to the result that the status quo and option B would
be much less effective to reach the objectives identified. 
6.2.        Feasibility
of implementation and sustainability
The options
vary considerably in their feasibility of implementation (extent to which each
option would attain buy-in from the MS, essential for a voluntary initiative)
and sustainability (extent to which momentum attained in the short term would
be maintained over a longer period of time):
·                        
Option B: given
that this option seeks to give strategic support to HEPA promotion based on the
EU PA GL but does not make specific demands on MS to commit to data monitoring
it is unlikely to face any serious implementation problems. However, since it
relies on voluntary action by the MS, without a specific framework for
prioritising this action and recording progress, this option is likely to
suffer from a lack of sustainability, as political momentum fades over time.
·                        
Option C: the
pragmatic nature of this option, reflected by the support of MS (Sport
Directors, HLG, Council Working Party on Sport), experts and stakeholders for a
monitoring mechanism based on a limited set of high-level and aggregate
indicators (as outlined in Annex III), is likely to result in few
implementation problems due to its relatively low costs and ability to fit
national circumstances. Moreover, the framework for collecting data and
recording progress engendered by the monitoring mechanism and the reporting to
the Council is likely to ensure the long-term sustainability of the initiative.

·                        
Option D: this
option faces serious problems of feasibility, since MS may not accept a
comprehensive set of targets and benchmarks against the indicators[125] and may not be willing to
invest high costs associated with collecting both qualitative and quantitative
data across a large set of physical activity-related indicators.[126] Moreover, given that not all
41 EU PA GL could be addressed universally by all 28 MS (see Annex III) there
is little EU added value in promoting such a comprehensive monitoring. If such
a comprehensive system was to be implemented and running, it might however
provide a degree of sustainability also in the longer term. 
6.3.        Efficiency
This section
analyses the extent to which each option would be expected to contribute to the
objectives for a given level of resources (cost-effectiveness). The principal
costs of all the options will consist of those associated with developing
and implementing policies to promote physical activity.[127] 
A number of
recent studies examined the costs of various interventions to promote physical
activity in terms of their effectiveness either in quality-adjusted life years
(QALY) or savings on health care costs. While the studies found highly variable
levels of cost effectiveness, all of the interventions examined were proven
cost effective i.e. they justified their costs, especially in light of the
vast costs for the economy of physical inactivity.
For example, a
comparative meta-analysis carried out in 2010 by the Liverpool Public Health
Observatory[128] provided evidence that HEPA promotion interventions are a
cost-effective way of preventing health problems. The review included four
types of interventions (‘brief’ interventions involving opportunistic advice or
discussions, the environment, school and workplace interventions, and mass
media campaigns), and found that in the vast majority of cases the benefits
outweighed the costs (usually in terms of health-care cost savings), often by a
very considerable margin (e.g. 11 to 1 in the case of cycling infrastructure, or
5.5 to 1 for a walking programme run by occupational health nurses). A similar
study in the US looked at seven types of public intervention to promote HEPA,
finding that each QALY cost from about USD 14-68 thousand, depending on the
type of intervention.[129]
A further
study looked solely at workplace interventions to promote physical activity,
finding cost savings from decreased absenteeism from USD 2.5-4.9 for every
dollar spent on the programme and reduced health care costs of USD 2.5-4.5 for
each dollar spent.[130]

While the
level of investment appropriate for each MS will vary depending on the scale of
the problem in the country in question, activities already being undertaken and
available capacity, the persistent lack of adequate physical activity in even
those MS that have had some success in increasing HEPA indicates that a
sufficient level of investment has not yet been attained. Moreover, since the
initiative will be voluntary, each MS will set any additional expenditure at a
level that fits national budgetary circumstances and political priorities. 
In this
regard, it is telling that evidence on both a micro and macro level
demonstrates that the benefits outweigh the costs for a variety of types
of government investment in physical activity promotion. In addition, the
economic benefits of such policies, in terms of increased productivity and
reduced health care costs are likely to be very large, thus justifying the even
substantial costs. 
In addition to
implementation costs, the cost-effectiveness of each of the options relates to
administrative costs for the MS and costs to the EU budget, as outlined in
Annex V. The table hereafter analyses the cost-effectiveness for each option.
Table 12: Cost-effectiveness
 Option || Cost / benefits || Value[131] 
 A || Although this option entails no additional costs for either MS or EU budgets, it cannot be described as a cost effective means since the gains it would be expected to achieve in terms of operational objectives 1 and 2 and the specific objective would be very minor or inexistent. || 0 
 B || This option entails only limited costs for MS' and EU budgets and it can be described as a cost effective means of achieving the small gains that would be expected in terms of operational objectives 1 and 2 and the specific objective. However, only minor improvements to MS policy are foreseen, and thus the benefits from investment in HEPA promotion policies (described in section 5 above) are not likely to be large. Moreover, comprehensive data that would allow for comparison is not likely to be achieved under this option, despite the (limited) administrative costs for the MS. || + 
 C || This option would entail some costs for MS budgets, but the largest benefits, as the MS collect data to feed into the monitoring mechanism, allocate resources to new physical activity promotion policies and then benefit from increased HEPA rates. While the majority of the costs would stem from policy changes, some expenditure from the EU budget would be required in order to set up, administer and maintain the data from the monitoring mechanism; the EU would also be expected to play some role in helping the MS to collect relevant data. || ++ 
 D || Like for all options, the majority of the costs would stem from policy changes. Due to the more extensive monitoring mechanism, including more detailed and greater number of indicators against which data would need to be collected, this option would entail the largest administrative costs for the MS, in addition to higher costs to the EU budget than those for option C. However, these relatively high costs would not be offset by commensurate gains in effectiveness. Since the benchmarks and targets included in this option are not likely to be politically palatable for the MS, the gains due to improved policy are likely to be small, thus reducing the overall efficiency of the option. || +/++ 
6.4.        Coherence
As outlined in sub-chapter 2.5.2, action to
promote HEPA contributes to the Europe 2020 strategy. More specifically,
options B, C and D are all coherent with EU policies in the field of health,
transport, social inclusion and research. However, it is difficult to ascertain
how the three options differ in their coherence to these policies. If only
because option C is likely to be the most effective, it can be described as
contributing more to EU policy goals than the other options. It is likely to
result in the greatest economic benefits and productivity gains, in addition to
the largest steps towards improving health, tackling health inequalities,
encouraging active commuting and facilitating social inclusions. In addition,
the coherence of options C and D strongly aligns with the policy tool proposed
for their implementation. The choice of a Council Recommendation appears to be
a coherent approach given that a) several "softer" EU policy documents
expressing a commitment to HEPA already exist and that b) the need for action
exists primarily at MS level.
7.           SUMMARY:
COMPARISON OF OPTIONS
Based on the
differing effectiveness and efficiency of the policy options, the following
table compares them against the baseline scenario (option A). Pluses indicate
that options rate more favourably than the status quo (e.g. because they are
more likely to be effective).
Table 13:
Comparison of options
   || Option A (baseline scenario) || Option B (push for increased policy coordination) || Option C (push for increased policy coordination and monitoring, based on key elements of the EU PA GL) || Option D (push for increased policy coordination and monitoring, based on implementing all EU PA GL) 
 Effectiveness || 0 || + || ++/+++ || ++/+++ 
 -   Specific objective || 0 || + || ++/+++ || ++/+++ 
 -   Operat. objective 1 (Pol. coordination) || 0 || + || +++ || ++ 
 -   Operat. objective 2 (Monitoring / Data) || 0 || 0 || ++/+++ || ++/+++ 
 Cost-effectiveness  (in relation to) || 0 || + || ++ || +/++ 
 -   Costs to MS || 0 || + || ++ || +/++ 
 -   Cost to the EU || 0 || + || ++ || +/++ 
 - Admin. Costs || 0 || + || ++ || +/++ 
 Feasibility/sustainability || 0 || + || ++ || + 
 Coherence || 0 || ++ || ++ / +++ || ++ 
7.1.        The
preferred option
Based on the
comparison of the three policy options against criteria for effectiveness,
efficiency, feasibility / sustainability and coherence, option C poses the most
appropriate and proportionate response to address the problems identified. It
would be slightly more effective than option D in achieving operational
objective 1, in addition to the specific objective. Moreover, concerning the
monitoring framework, it presents a more cost-effective choice, as the
mechanism it proposes entails smaller costs than the more extensive set of
indicators, benchmarks and targets proposed under option D. This more flexible
approach to the monitoring mechanism also increases the political feasibility /
sustainability of option C, which has the strongest possibility of engaging the
MS over the medium term, a key aspect of success for any voluntary initiative.
While all three options are coherent with EU policy, option C, through its
greater effectiveness and the proposed tool of a Council Recommendation, will
lead to larger steps towards the achievement of wider policy objectives.
Overall, there is an advantage in implementing option C.
8.           MONITORING
AND EVALUATION
The external
study carried out in the context of this Impact Assessment (see Annex III)
identified a set of 23 indicators against which the evolution of HEPA rates and
HEPA policies and the implementation of the EU Physical Activity Guidelines can
be measured. 
Data on these
indicators will be collected as part of the EU monitoring mechanism foreseen in
the preferred option (option C) and will also provide the lion’s share of
information needed to monitor and evaluate the initiative as a whole: the
general, specific and first operational objective will be directly informed by
data collected against the indicators. Two other indicators are foreseen to
monitor the implementation of operational objectives 1 and 2: the first
indicator relates to enhanced policy coordination at EU level and should cover
the extent to which MS participate in meetings and contribute in the reporting
about the implementation of the Recommendation; the second indicator, which
relates to the collection of comparable and comprehensive data on HEPA and HEPA
policies, will measure the extent to which the data on the 23 indicators is
collected and made available.
Progress in
implementing the Council Recommendation will take the form of regular reports,
every three years, from the COM to the Council. Such reports would include in
particular an assessment/evaluation of the progress made based on the data
collected via the monitoring mechanism (e.g. country snapshots) on the one
hand, and, on the other, wider information regarding HEPA policy development
and implementation of the EU PA GL in the MS (e.g. structural developments and
processes to promote HEPA). The working structures for sport, in particular the
XG SHP, and the physical activity focal points in the MS (to be established)
would play a key role in providing input for this report. The draft report, as
agreed by the XG SHP, would be transmitted to the Council Working Party on
Sport. Other relevant fora, in particular the HLG, would be consulted and
regularly informed at key stages of this reporting process. A full evaluation
of the implementation of the Council Recommendation should be made after 6
years, involving an external contractor.
9.           ANNEX
I: CONSULTATION OUTCOMES
Over the past years, Member States (MS),
the European Parliament, experts, sport stakeholders and the general public
have been consulted at different levels about their views regarding the need of
and scope for the promotion of physical activity (PA) in an EU context, either
directly or indirectly related to the planned EU policy initiative on
health-enhancing physical activity (HEPA), which is proposed to take the format
of a Council Recommendation. After the adoption of the Communication on sport in
January 2011[132],
which includes an action point to consider such a proposal, the Commission (COM)
has regularly presented its plans and the work in progress for this initiative
to the policy level and to stakeholders and sought feedback within different
fora. This was notably done at all the events and meetings referred to
hereunder as of early 2011, some of which were organised by or with support from
the COM.
Section 9.1. below includes the discussions
with the Member States in EU structures for sport and for health. The proposed
initiative is mainly addressed to public authorities and therefore this section
is considered particularly relevant. It reflects Member States' views on the
idea of further promoting HEPA by means of a new EU policy initiative based on
the EU Physical Activity Guidelines (EU PA GL), and the proposed monitoring
framework.
Sections 9.2. – 9.4. summarise
consultations with the European Parliament, HEPA experts, and sport
stakeholders and the general public.
9.1.        Member
States (Council structures, informal level) 
9.1.1.     EU
structures for sport
The wish to address the promotion of sport
and PA with a health-related purpose in the EU 'sport' context goes back to the
informal cooperation preceding the inclusion of sport in the Lisbon Treaty,
when MS gave the topic of 'sport and health' priority within their discussions
under the EU rolling agenda for sport. Following a 2004
EU-funded study on young people’s lifestyles and sedentariness that recommended
the development at EU level of minimum standards for active living[133], a political process was launched
with MS under the UK Presidency and led to the
set-up of an informal EU Working Group 'Sport
& Health', chaired by the COM and mandated to 'promote the
role of sport in a healthy lifestyle for all age groups in Europe', which held
its first meeting in 2005 (and continued meeting until mid-2011)[134].
In the run up to the Treaty and in
anticipation of the new EU competence for sport, the COM's 2007 White Paper on
Sport[135]
set a new strategic framework for the EU's dealing with sport, including PA,
and, by foreseeing concrete actions regarding policy and funding, gave
direction for the cooperation also in the field of HEPA with and between the MS
at EU level. Most importantly, this led MS and the COM to work together jointly
(WG Sport & Health), and with the support of a special group of HEPA
experts appointed by MS, towards the EU Physical Activity Guidelines (EU PA
GL)[136].
These GL emphasise the importance of a cross-sectoral approach and provide 41
concrete recommendations mainly addressed to policy makers in the MS. The
drafting of these GL was closely coordinated with the COM's activities in the
field of health led by DG SANCO, notably the Strategy for Europe on Nutrition,
overweight and obesity-related health issues following the respective 2007
White Paper[137].
The GL were confirmed by EU Sport Ministers in 2008. The implementation of the
GL was subsequently discussed in the WG on Sport and Health and progress in
implementing the GL themes has inter alia been recorded in an
"Implementation table"[138].
Work on collecting information for this table has been continued thereafter
(last update in June 2012). These discussion and the information in the table
show that some MS have already used the GL as a source of inspiration, but
the implementation has so far remained patchy both with regard to the
number of MS and with regard to the number of guidelines as well as guideline
themes. In the latest update, 16 MS reported to have – at least partly –
implemented the GL at national level (further details below). According to the
2010 progress report on the implementation of the Strategy for Europe on Nutrition,
Overweight and Obesity-related Health issues, that is also measured against two
indicators on PA, "nearly half of the MS have fully implemented their
guidelines"[139].
The 2013 final evaluation notes the following: "However, as is the case
for several of the indicators in the 2010 implementation report, it is
difficult to assign concrete meaning to the findings. Both indicators are open
to interpretation and could result in inconsistent reporting by NCPs [National
Counter Parts] in different MS.[140]
After the inclusion of sport in the Lisbon
Treaty, HEPA naturally also became a topic for MS' cooperation in the framework
of the EYCS Council. The preparations of the first multi-annual cooperation
plan for Sport under the Polish and in particular the Hungarian Presidency
(2010-2011) confirmed MS' wish to give due attention to the promotion of PA
in their future cooperation at EU level. The Council at its meeting on 11
May 2011 accordingly adopted a Resolution on the EU Work Plan for Sport[141] that identifies HEPA as a
priority theme and called for the establishment of an Expert Group on Sport, Health and Participation (XG SHP)
which should replace and build on the work in the former WG on Sport and
Health. The XG SHP got the mandate to assist with the implementation of the
Work Plan, namely to "explore ways to promote health-enhancing physical
activity and participation in grassroots sport" and "to identify
measures by mid-2013". To achieve this, the group composed of experts
appointed by MS, agreed on a work schedule and defined five deliverables. The
group's first deliverable, 'input for the planned EU initiative in the field of
HEPA', is particularly relevant for this IA exercise, since it consisted
of a) gathering further information about the implementation of the EU PA GL,
or the principles underpinning them, in the EU MS and b) exploring ways to
monitor the implementation of the GL with the help of a limited set of
indicators. The group's first set of deliverables, including deliverable 1, was
submitted to the Council Working Party on Sport and presented at the WPS
meeting on 4 July.[142]
With regard to the first aspect (a), the group provided input and/or updates to
the existing implementation table and came to the conclusion that 16 MS were
implementing (at least part of) the EU PA GL, notably the following: AT,
BE, CY, CZ, DE, ES, FI, FR, HU, IE, LT, LU, NL, PL, PT, UK (England and
Scotland). Moreover, MS experts in the XG replied to a questionnaire aimed at
gathering additional information about the implementation of the GL. According
to the answers provided, the identified barriers and challenges for
implementation in the MS were related to the cross-sectoral cooperation, the
lack of a leading entity, the lack of a monitoring mechanism and
the need to ensure funding. The strengths of the GL were
identified to be the availability and the sustainability of their content; the
weaknesses were the broadness of their content and a perceived lack
of information for the monitoring of their implementation. Secondly, the XG
discussed and provided oral and written input for the idea of a framework to
monitor the implementation of the GL. Apart from its general support for a
monitoring framework, the XG provided specific comments on the draft table of
indicators, as prepared and presented by HEPA experts (forming part of the
study consortium) and, at its meeting on 27 June 2012, endorsed the revised
draft of that table (as included in annex III of this IA).[143] The XG SHP accordingly
"agreed that deliverable 1 should consist of the group's advice to the
Council to call for a new EU policy initiative to promote HEPA, building on the
EU PA GL. Such an initiative should usefully introduce a soft monitoring
framework, including a set of indicators. The group also recommended that the
COM's proposal for such a monitoring framework should take inspiration from the
draft table of indicators revised by the XG."
Also at the informal level, the COM regularly
informed EU Sport Ministers and EU Sport Directors on its plans in the field of
HEPA, including the planned proposal for a new EU policy initiative, as
announced in the 2011 Communication on sport, and sought MS' views. In the run
up to the first EU Work Plan for Sport, EU
Sport Ministers at their meeting in Gödöllö, on 23 February
2011, discussed the planned EU incentive measures for sport and PA (2014-2020)
noting the need to concentrate on issues where EU action had an added value.
HEPA was highlighted as one of the priority fields in that regard.[144] In the context of the then
expected COM proposal for a sport sub-programme (end of 2011) and corresponding
negotiations in the Council, Sport Ministers at their meeting under the PL PRES
(13-14 October 2011, Krakow) welcomed the idea of including HEPA as a priority,
with FI and HU stressing that HEPA and the promotion of grassroots sport should
be robustly presented in any proposal.[145]
At their Informal Meeting under the Cyprus Presidency (Nicosia, 20-21 September
2012) Sport Ministers held a joint discussion with participants of the EU Sport
Forum (see below) on the contribution of sport and PA to Europe's economy and a
(closed door) exchange of views on sport and health with a focus on active
ageing.[146]
On the latter, Ministers highlighted the importance of promoting active ageing
in the national policy context and listed the main initiatives taken (BE, DE,
FI, FR, HU, IT, LT, NL, PL, PT, RO, SE, UK). Some MS (DE, NL, SE, UK)
explicitly supported the sharing of best practices in that area at EU level.
On the EU's role in HEPA promotion, HU wished to see the EU supporting
the development of national strategies, including for PA at the work place.
Several MS (FI, FR, UK) stressed the need for more cross-sectoral cooperation
between Ministries and FR said it would specifically welcome an EU
impetus to that effect. The idea of a monitoring system was explicitly
welcomed by PT (system to evaluate progress), FR (common indicators, health
benefits, wellbeing benefits, economic benefits), FI (need for better and
comparable data) and NL (COM support through light monitoring). SE questioned
the need for a Council Recommendation and remarked that Council conclusions
providing for indicators based on which MS could evaluate progress could be
more appropriate.
Also at the level of EU Sport Directors, HEPA has been a
recurrent topic for the discussion. At their meeting in Gödöllö (27-28 June
2011), Sport Directors addressed the importance of cooperation with the sport
movement when implementing the new EU Work Plan, including in the field of PA.
Sport Directors under the PL PRES (15-16 December 2011, Gdansk) discussed the
COM's proposal for the Sport Chapter under Erasmus for all; AT, DE, ES, FI, HU
and PT expressed general support for the choice of topics (i.e. including
HEPA), with FI and HU noting that HEPA should be a key priority. At their
meeting under the DK Presidency (31/5-1/6/2012, Copenhagen), Sport Directors
had a focused exchange of views on the promotion of HEPA based on a PRES
background paper outlining the EU policy context for HEPA and asking for MS'
feedback on the impact of the EU PA GL and on how to overcome barriers for
their implementation. In that context, MS discussed the idea of an EU
policy initiative and more concretely the proposal for a monitoring framework
including the indicators to further the implementation of the EU PA GL. At that
meeting, the French chairman of the XG SHP informed about the group's conclusions according to which barriers for
implementing the EU PA GL consisted mainly in a lack of cross-sectoral
cooperation, a lack of a leading entity, a lack of a monitoring system and lack
of available funding. In addition, an external expert illustrated how to foster
policy development regarding HEPA promotion and the implementation of the EU PA
GL. He noted the continuum between sport and PA and explained that the concept
of HEPA was a wider one beyond leisure-time PA and including e.g. PA at work or
physical transport He stated "this has implications for policy
development. For HEPA promotion, several factors come into consideration
(personal, physiological, psychological and behaviour setting, political
environment). HEPA promotion as a policy has to take into account that the
problem will not disappear any time soon; it is complex and it is highly
interdependent. Adequate policy instruments therefore have to be sustainable
and flexible, diverse and inter-sectoral. The EU PA GL reflect these
needs." A second external expert presented the on-going work at EU level
to develop the framework to monitor the implementation of the EU PA GL. He
inter alia stated: "The evidence is there, but policy implementation
faces so many barriers; this has been the situation over many years. HEPA
should be a core interest of society in general and not just of one sector.
There is a need to regularly ask questions e.g. about the daily use of bikes,
hours of PA in schools, national schemes to promote PA at the work place,
community programmes for senior citizens, etc., in order to increase the
chances of better PA promotion. The information was there, but needed to be
updated and put together." In the subsequent discussion and in reply to
the PRES background paper BG, CY, FI, FR, HU, IT, MT, NL, PL, PT, SE, UK
confirmed the importance of HEPA promotion and almost all of them expressed
support for further EU action based on the EU PA GL, including a monitoring
scheme. NL noted that the GL were a useful instrument to check the state of
play regarding the national policy; NL considered that national policy was
complying with the GL without following each separate GL, noting that a lot
of work was in progress and that sport and PA were leading topics in national
discussions about lifestyle. The challenges remained in cross-sectoral and
multilevel cooperation. The idea of monitoring the implementation of the
EU PA GL was useful, including a limited set of indicators with data that
should lead to policy action (avoid a data cemetery); MS could learn
from policy results in other countries, but it should remain a
responsibility of the MS to carry out the monitoring. Sport participation
and PA should be part of the EU statistical programme and thus become part of
'EU Monitoring'. PL welcomed the EU PA GL as a comprehensive document that could
be useful as a checklist for existing strategy papers; PL was using the GL at
all levels and in different sectors; regarding monitoring, the work undertaken
was appreciated and PL looked forward to further developments. FI stressed that
the promotion of HEPA involved different stakeholders, required continued
cross-sectoral work and continued efforts; FI had set up a cross-sectoral
HEPA steering group in 2011, which was developing new strategic guidelines and
to address the challenge to involve other sectors than health and sport.
Regarding monitoring, FI noted that the XG SHP was on the right track and looked
forward to the monitoring scheme. CY expressed full support for the
proposed monitoring scheme, based on reliable indicators, which could be a
means to ensure regular cooperation between MS and to evaluate the
implementation of the GL. The EU PA GL formed an important part of CY strategic
plan 2020 “Right to PA: citizens in action” (published mid-2012). The main
challenge was how to develop a new culture on PA (e.g. CY and DK were two
different worlds and had different mentalities with regard to e.g. schools). UK
had established a cross-sectoral committee on public health, covering levels of
sport and PA. While a monitoring scheme was the way forward, UK experts in the
XG SHP were of the view that there should not be too many indicators. In
PT the main challenge remained inter-sectoral cooperation. Close
monitoring of the GL was supported as a way to increase cross-sectoral
cooperation and to mobilise civil society. The set of indicators was a neutral
way of measuring the implementation of the EU PA GL and would allow for their
close follow up. PT hoped that this mechanism would provide more information
to evaluate the impact of its national policies and measures. HU confirmed
that the biggest challenge at national level was the lack of an
inter-sectoral approach, although sport was in the same Ministry as Public
Health. Monitoring was considered a good idea for a country like HU, since it
could see how other countries were dealing with the problems and since it could
encourage the engagement of national authorities. HU looked forward to the
indicators. It would be useful if the EU statistical programme could provide
data for the monitoring exercise. FR recalled that the EU PA GL were adopted
under its Presidency term, explained the specific HEPA promotion programmes in France
and welcomed further action to follow up on the EU PA GL by means of
a monitoring scheme. IT informed about the country's cross-sectoral
approach to promote PA, greeted the activities by the XG SHP noting that they
should get more support in the future, and welcomed the idea of monitoring the
implementation of the GL; the evaluation of outcomes would be useful. MT
presented the national action to promote PA, noting that best practice had
illustrated the importance of a life cycle approach. Monitoring was in
principle a good idea, but needed to be sustained by adequate budgets and
needed to account for national differences; benchmarks could be
identified. SE echoing NL, considered that it was already complying with the
GL, cross-sectoral cooperation was indeed essential. In SE's view,
indicators could be useful, while the monitoring should remain the
responsibility of the MS. LU informed about its national action plan
targeting the whole population “bouger plus, manger mieux" and noted the crucial
role of sport clubs to promote PA. Monitoring could be supported in
principle. BG referred to four national programmes aimed at promoting HEPA.
PRES concluded that the discussion provided a lot of constructive input to the
COM for the further work and that everybody agreed on the importance of
monitoring and of having the right indicators.
The discussions
at the policy level within the formal and informal EU structures for sport
described above led the Cyprus Presidency to prepare Council conclusions on HEPA
in the second half of 2012 that were adopted by the Council on 27 November. These
Council conclusions on promoting HEPA include the following key
elements:
(a)         
support for the
EU PA GL as a basis to encourage cross-sectoral policies to promote PA by
offering guidance to the MS in the development of their national strategies on
HEPA,
(b)         
recognition of PA
being one of the most effective ways to prevent NCDs and on its positive
effects on mental health and cognitive processes as well as for health systems
and the economy at large,
(c)         
confirmation of
the great disparities between MS' approaches and the scope for further
improving the implementation of HEPA policies following the GL;
(d)         
a call on MS to
continue progress in developing and implementing strategies and cross-sectoral
policies to promote HEPA taking into account the EU PA GL; to support
initiatives aimed at promoting PA within the sport sector,
(e)         
an invitation to the Presidency, MS and the
COM to intensify cooperation between policy areas
that, in line with the EU PA GL, have responsibility for promoting PA; to
improve the evidence base for policies designed to promote HEPA
(f)           
an invitation to the COM, in light of the EU PA GL, to make a proposal for a Council
Recommendation on HEPA, and to consider including a light monitoring framework
to evaluate progress with the help of a limited set of indicators that build to
the largest possible extent on available data sources; to consider establishing
an annual European Week of Sport.
9.1.2.     EU
structures for health
The promotion of HEPA has also been the
subject of high-level discussions between MS in the health policy field. In the
context of the Strategy for Europe on Nutrition, Overweight and Obesity-related
Health issues ('EU strategy') the High Level
Group on Nutrition and Physical activity (HLG), set up in 2007,
got the mandate to discuss solutions to obesity-related health issues in the
EU, including PA. As an input to this work coordinated by DG SANCO, the COM
(DG EAC) regularly presented its activities and plans in the field of sport and
PA promotion. The concrete plans relating to the policy initiative were shared
with the HLG at two meetings, on 3 February 2011 (11th meeting) and on 14 June
2012 (15th meeting). 
The monitoring framework and set of
indicators was discussed in June based on a background paper prepared by the
COM services. At that meeting the HLG was invited to react, particularly on the
proposed monitoring framework. The chairman noted that monitoring was an
important aspect of the work of the HLG. Given that already existing databases
in cooperation with the WHO would be used, HLG members were invited to welcome
the initiative as it reinforced existing policy synergy without carrying an
additional burden, given that it took account of existing monitoring tools.
In particular the following comments were made: SI informed that its Ministry
of Health was very interested in the new development. The proposed
indicators were based on sound scientific evidence and responded to the needs
of the MS. SI noted that the national HEPA Strategy 2007–2013 had had
weak implementation, mainly due to insufficient cooperation among sectors.
SI proposed adding a few indicators on inter-sectoral cooperation. In
conclusion, SI would support the policy initiative. FR pointed out that MS had
different administrative situations and therefore multi-sectoral realities. This
needed to be taken into account when identifying indicators and when comparing
information on implementation. Currently, different tools used to evaluate
PA led to different results. The chairman welcomed the HEPA policy
initiative on behalf of the HLG. Particularly the focus on monitoring was
appreciated. The WHO Europe representative informed that the running
database (NOPA) was in the process of being updated. In order to keep it alive
the cooperation of and input from the MS was required. Following the discussion
at that meeting in June, the HLG provided written comments to the two
questions in the background document, including the following:
Question 1: "What
are the main challenges? What steps would need to be taken to ensure more
sustainable promotion of HEPA across sectors?"
On that
question HLG replies were as follows (slightly shortned):
DE: "One
major challenge is the fact that prevention is a multi-sectoral task
which also affects different areas and levels of policy. This is why we need
targeted co-ordination across the boundaries of various political sectors. In
DE, such a co-ordination effort has to be based on the federal structure, with
the aim of observing regional peculiarities while at the same time achieving
purposeful co-operation. It is also necessary for other important social actors
in the area of prevention, such as the bodies responsible for providing social
insurance benefits, the sports associations or employer and employee
associations with their different responsibilities and interests to be
included, as far as possible, in any co-ordinated action."
CH: "The main
challenge is to get all interested partners from all different fields on
board, to pursue the same goals and support the same strategies. The EU
PA GL provide concrete policy recommendations for each of the relevant sectors of
society, such as sport, health, education, transport, urban planning, working
environment and services for senior citizens. CH implemented a lot of the
recommendations from the GL. In CH the cross-sectoral implementation has made a
lot of progress in recent years and one can see growing involvement and number
of actions by other sectors."
FI: "Traditions
and cultures vary in different countries. Cross-sectoral co-operation is
difficult to start if there are a lot of barriers between different sectors."
EE: "One
of the main challenges to promote HEPA is the cross-sectoral issue and
the cooperation between different public and private sector organisation and
the sport movement. Promoting HEPA is financed by different organisations in
different areas. There is surely the need to ensure funding. EU
should promote and support the sharing of best practices in the EU
regarding HEPA and participation in sport, inter alia through support for
projects and public awareness campaigns."
SI: "SI
agrees that the influence of EU has a positive impact on countries' work and
the development of the national policy. We believe that EU PA GL do offer
guidance in the development of our policy for HEPA, emphasising in
particular the need for a more effective cross-sectoral approach. Regardless this
positive influence on our country's work, we still confront with some
challenges. The main challenge in SI is cross-sectoral collaboration (SI
would require stronger and sustainable cross-sectoral collaboration, which
would include open communication, better conditions and establishment of
structural connection options, i.e. establishment of working group for this specific
area of collaboration)." 
NL (informal
reaction): "The main challenges momentarily are to organise long term
concerted action, without a certain binding regulation and with strain on the
budgets, to establish a shift in structure and culture that mild and
moderate exercise is normal and even strenuous exercise can be fun; the
concerted action being a policy mix of 1) information/promotion, 2) effective
HEPA methods & supply of sport/fitness and 3) measures on physical, social
and financial environment; to persuade local governments to continue their
support to sport and to extent their policy to HEPA. In NL the collaboration
between sport sector and health sector is promising; the cooperation with the
policy domains of infrastructure, traffic and finance is momentarily less
strong. Important steps may be to designate a national agency for HEPA
promotion which has trans-sectoral power and/or to make it compulsory to
take into account the effect on the amount of light PA in HEPA for every new
infrastructural plan and every relevant new policy or law/decree, to commission
a group of enthusiastic youngsters together with scientists to identify the
real thresholds for PA and exercise in society, to find new ways of persuading
people and to look for innovative measures in favour of frequent light PA and
daily moderate exercise that will be accepted in (almost) all groups of
society."
IT: "The EU PA GL are in line with the
policies adopted at national level, based on an inter-sectoral approach,
according to the principles of the “Health in all policies”. PA promotion, in
fact, is part of the National strategy “Gaining Health”, a coordinated action
plan for counteracting 4 leading risk factors for non-communicable diseases
(physical inactivity, poor nutrition, alcohol abuse, tobacco consumption) led
by the Ministry of Health and based on institutional alliance with Regions and
Municipalities and partnership with different private sectors, civil society,
consumer associations. The main challenges for promotion PA are to ensure
greater continuity of the actions identified as 'best practices' or 'evidence
based' and promote a better integration between health policies and other
sectors' policies (transport, education, urban organisations) to ensure
public policies aimed to increase opportunities for all citizens for an active
lifestyle. The promotion of health through PA requires the adoption of policies
that facilitate healthier choices, so that PA is the easiest choice. It is also
needed to adapt the strategies to promote PA to the different 'local' contexts
and resources, involving broad sectors of society. Strategies to promote PA,
therefore, require integrated interventions that should include facilities for
leisure and sports, workplace and healthcare settings, as well as transport
planning, traffic control, planning of buildings and urban environments and
information activities in the territory. The inter-sectoral approach allows
implementing interventions that modify unhealthy behaviours, promoting
healthier individual choices by changing the environment. To increase PA and
discourage sedentary behaviours it is crucial to address the determinants of
environmental, social and individual physical inactivity and implement
sustainable actions through collaboration between multiple sectors at national,
regional and local levels. Urban planning, therefore, must be considered a
fundamental instrument for the protection of individual and collective health.
Currently, relations between the urban environment and health are becoming more
evident. The school and the city are, or should become, learning spaces,
experience and relationships to help young people. The public health sector
should implement interventions designed to increase PA for specific target of
population, such as elderly people or people with specific diseases (PA
prescription), taking into account the environmental context of PA and the
balance between benefits and possible increased risks of higher levels of PA. Communication
for health is also very important to raise awareness of the health benefits of
PA, so it is necessary develop information campaigns to promote PA but also
to inform people about the opportunities exiting at local level to practice PA
(not only “sports” but also walking, bike-sharing in the cities, “walking bus
to school” for children, etc.)."
Question 2: "What do you think of the
idea of a monitoring mechanism to promote the implementation of the EU PA
GL?" 
On that
question, HLG members provided the following comments (slightly shortened):
DE: "In
principle, the Federal Ministry of Health supports such a monitoring
mechanism. The indicators developed to monitor the implementation of the
guidelines' principles will make it possible to determine progress and
diagnose fields of action within the many areas in which efforts can be
undertaken to promote PA. At the same time, comparative studies among countries
can be conducted and priority areas in the individual countries examined in
greater detail. DE nevertheless wishes to draw attention to the fact that many
of the indicators in question are not being recorded nationally at the present
time and that, even at EU level, not all of the necessary data are
available. The decision to implement a monitoring process, using the
corresponding indicators, should not lead to a situation where new data
would need to be collected at national level or extensive reporting be required.
To the contrary, as far as possible, already existing studies/data sources
should be used exclusively."
CH: "Of course
a monitoring mechanism to promote the implementation is welcome.
FI: "I support
warmly the idea of a monitoring mechanism."
EE: "EE fully
supports the idea of
a monitoring mechanism to promote the implementation of the EU PA GL. The
monitoring mechanism should be simple and concentrate on the data, which already exists or is collected by the MS. There should be no costs for MS.
The monitoring mechanism should be organised by the COM and
provide added value for promotion HEPA and
exchanging the best practices between MS. Estonia has already adopted the
national PA development plan for years 2011-2014. Development Plan main objective
is, for the year 2014 a total of 45 per cent of the population should be
involved in regular PA."
SI: "SI supports the
idea of monitoring mechanism to promote the implementation of the EU PA GL. We
consider all of the following approaches useful: a) indicators on direct
effects, b) indicators on thematic groups and also c) detailed indicators. We
believe that the indicators on direct effects are good approach because of the
simple implementation and could be monitored each year. We also support more complex
approach which could be implemented with detailed indicators on all 41
guidelines. In our opinion this
could be monitored after a decade (10 years) and could than offer the
possibility of changing the temporal niche. Indicators on thematic groups with
medium number of indicators are an excellent approach, because it includes both
a complexity and a simple implementation. In our view this kind of proposed
approach could be monitored in a period of 2 years. Our suggestion would
be to strongly integrate all these three approaches (a. indicators on direct effects, b. indicators on thematic groups and c. detailed
indicators) into one structural approach e.g. into a pyramid approach, where
they can mutually link and complement. In a decade we could therefore monitor
all these three strongly integrated approaches within a proposed period of time
(i.e. a. after each year, b. after 2 years and c. after a decade). In addition to this we would also like to highlight
the importance of financing mechanism. We believe it is necessary to plan
the financial mechanism carefully, in light of financial crisis and lack of
resources."
NL (informal
reaction): "This seems to be a good idea because the rule of thumb
‘what is being measured will be done’. On the other hand, national and
local governments may be reluctant to agree with that because of perceived
loss of authority, the possible administrative burden and future costs."
IT: "The monitoring
tools are essential to define the priorities in public health. To know the
problem and to guide the choices of decision makers and citizens through the
promotion of PA, it is necessary to have a system of collection, analysis,
interpretation and communication of data that is able to provide accurate
information on PA practiced, on measures implemented and results achieved."
CZ: "We fully
support activities promoting PA and fully appreciate that full advantage of
work on NOPA is taken; However, mentioned EU PA GL were prepared by very close
group of experts (sport experts mainly); these guidelines are more focused on
sports (grassroots sports) than PA;[147]
these guidelines were endorsed only informally by ministers for sport even though a lot of proposed activities
(which are quite specific) is focused on health sector (health care, health
insurance etc.). The focus of the EU guidelines and following activities on the
health sector is quite strong. This could cause some inconveniences as it is
not easy for the EU to bring added value in areas the areas where it has no
competencies, the division of competencies between the Union and MS as
provided by the Treaty shall be taken in to account." 
Beyond discussions in the framework of the
'EU Strategy', the Council
structures for health have addressed the need
to promote a healthy lifestyle, including PA. The Council conclusions of 1-2
December 2011 on "Closing health gaps within the EU through concerted
action to promote healthy lifestyle behaviours"[148] recognise that "health
gaps are understood as being population differences in premature mortality,
morbidity and disability between and within MS" and that "these arise
in part from the major unhealthy lifestyle behaviours, i.e. (…) lack of PA".
The Council also recognises that "Improved evaluation and assessment can
help determine whether strategies and policies are effective for addressing
health inequities and the health needs of populations. It can thus support MS
to develop and implement effective public health strategies and appropriate
infrastructure". The Council commits in this text to "accelerate
progress on combating unhealthy lifestyle behaviours, such as (…) lack of PA
leading to increased incidence of NCDs (…), which are recognised to be
important causes of premature mortality, morbidity and disability in the
EU". It calls on MS to "continue, intensify and/or develop
policies and actions promoting healthy lifestyle behaviours",
"make optimal allocation of resources especially in relation to health
promotion and prevention activities". It calls on MS and the COM to "assess
indicators to monitor progress resulting from interventions focused on the
aforementioned lifestyle behaviours" and to "reinforce and continue
action to support healthy lifestyle behaviours including encouraging the
development of urban and social environment policy conducive to PA for
all". The Council calls on the COM to "consider the need for (…)
additional data and information on unhealthy lifestyle behaviours. (…) This
should be obtained from sustainable health monitoring systems (…) which might
be established at EU level." In addition, the Council conclusions on
"Healthy ageing across the lifecycle"[149] adopted on 7/12/2012 recognise
that "lifestyle behaviours are amongst the main determinants of health and
addressing them through inter-sectoral action remains one of the challenges for
achieving active and healthy ageing for all"; they invite the MS to "adopt
an approach that shifts the focus towards health promotion and disease
prevention", to "promote policies and actions that sustain the
health of working age people leading to a healthy workforce, as a prerequisite
for productivity and growth" and to "enhance and strengthen
coordination (…) among MS promoting inter-sectoral action"; they invite
the COM to "support better use by the MS of the EU Physical Activity
Guidelines", and they invite the MS and the COM to "promote
strategies for combating risk factors, such as (…) lack of PA".
9.2.        The
European Parliament
The promotion of PA and
participation sport has also been a recurrent topic for the work of the
European Parliament (EP). For instance, when voting the budget for sport
(i.e. Preparatory Actions 2009-2012), the Parliament has regularly given
priority to the topic of HEPA. In its 2012 Resolution
on the European dimension in sport[150], the
EP considers that "sport is a key factor for
health in modern society", that "promoting PA and sport makes for
significant savings in terms of public expenditure on health" and that
"a key motivating factor behind citizen involvement in sport and PA is to
improve personal health and well-being". It subsequently "urges the
MS to establish clear guidelines to integrate sport and PA into all levels of
education", "recommends that the COM encourages the practice of sport
among senior citizens as it helps to promote social interaction and high rates
of good health", "underlines that sports at all ages is an important
area of great potential for increasing the overall health level of Europeans
and therefore calls on the EU and on MS to facilitate engagement in sport
and to promote a healthy lifestyle fully exploiting the opportunities of sport,
thereby reducing spending on healthcare", "calls on the COM and MS to support more strongly the role of health
professionals in the promotion of sports participation and to examine how
health insurance providers could offer incentives as a way of encouraging
people to take up sporting activities", "stresses
the great socially-integrating power of sport in many areas, including (…) the
promotion of good health", "encourages the COM and the MS to
acknowledge the importance of sport as a means of promoting (…) public
health", "notes that coaches can provide guidance for young people to
develop a healthy lifestyle", "calls on the
COM to organise a ‘European Day of Sport’ every year
which promotes (…) the benefits of sport in terms of public health". 
9.3.        HEPA
Experts
Meetings of the HEPA Europe network[151]
HEPA Europe is a (pan-) European network
launched in 2005 that aims at promoting HEPA and, together with other relevant
institutions and organisations, at improving coordination in PA promotion
across sectors and administrative structures. HEPA Europe closely collaborates
with the WHO Regional Office for Europe (WHO Europe). Members are generally
organisations or institutions, and to a lesser extent public authorities,
active in the areas of research, promotion of PA and sport, education/training,
and/or health promotion - all representative HEPA
organisations from Europe today appear to be
members of the network. The concept of HEPA as a bridge
between PA/sport and health is gaining ground across Europe, with a constantly
increasing membership (applications via WHO Europe) and an increasing number of
activities (seminars, working groups, database, website, publications).
HEPA Europe organises annual events (meetings
and conferences) that bring together hundreds of participants active and/or
interested in the field of HEPA (academia, research, civil society
organisations, sport organisations, public authorities). Since 2008 the COM has
regularly participated in these events and presented the emerging EU level
activities in the field of HEPA (Public Health Programme, Platform on Diet,
Physical Activity and Health, White Paper on Sport, White Paper on Obesity, EU
PA GL, Communication on sport, planned EU policy initiative, etc.).[152] The meetings were a good
opportunity to get feedback on the EU PA GL and to confirm that they were in
line with the latest scientific and sociological evidence. The meetings
repeatedly confirmed the huge need for more "PA advocacy" (i.e. efforts
to explain the benefits of PA on public health, and in particular to explain
the financial effects of physical (in)activity). It was inter alia noted at
these Annual Conferences of HEPA Europe that
·                        
"The cost of reaching a
public health benefit through PA is generally far lower than reaching the same
benefit through medical treatment, but politicians and policy-makers were
generally not aware of this. In both Europe and the USA, public health
institutions tend to have almost no members from the PA area."
·                        
"Sport clubs generally
perceive themselves as more health-promoting than they are in reality. However,
the effect of sport clubs on public health can be greatly increased
through public policies and programmes, as are in place e.g. in FI and NL. In
the latter country, a system is being put in place to reward sport clubs for
concluding cooperation agreements with schools from their area, apparently with
good results."
·                        
"HEPA as a
cross-sectoral concept to enable people to move more as part of their daily routines
is a concept that is gaining ground in Europe." 
·                        
"The EU PA GL made an
important contribution to the growing consensus about what HEPA is and why it
should be supported by the public sector. At the same time, approaches and practices
in different MS remain divergent in terms of quality, quantity, budget
support etc., so that exchange of good practices in this sector deserves
support and can make an important difference in terms of the EU
population's lifestyles in the longer term."
·                        
"Policy-makers can shape
the urban environment and thus improve the conditions for HEPA (planning of
streets, sidewalks, cycle paths, footpaths, lighting, safety, benches to sit
on, parks, playgrounds, sport clubs, sport fields, location of supermarkets,
etc.). While excellent scientific tools exist to help policy-makers make
informed decisions, most municipalities in the EU do not use such tools yet,
which leads to sub-optimal (or plainly wrong) decisions."
·                        
"Cooperation among the
relevant departments (health, education, youth, sport etc., at national,
regional and local levels) is often a serious problem. Low awareness of
the benefits of an active lifestyle is a problem among both policy-makers and
citizens in most countries."
·                        
"Partial PA programmes
now seem to exist in most MS, but only as parts of
either a health strategy or a transport strategy. Few MS have comprehensive
cross-sectoral HEPA strategies. Yet such strategies bring the best results."
·                        
"The importance of
physical activity (PA) is not only linked to tackling obesity (only 10%
of all benefits), though it must be considered the entering point for HEPA on
the European agenda."
·                        
"Today there is evidence
that PA has a much broader impact on health, in particular chronic stress
being the greatest disease these days."
Very importantly also for this Impact
Assessment and the intended structures for the implementation of the
Recommendation is the creation of the HEPA Europe EU Contact Group: The 4th Annual Meeting of HEPA Europe proved to be of
considerable for the implementation of the 2nd action of the
"Pierre de Coubertin" Action Plan ("The COM will support an EU Health-Enhancing Physical
Activity (HEPA) network [...]") where COM together with HEPA Europe's Steering Committee
could find common ground on modalities for cooperation and, in particular, the
creation of an EU HEPA network based on the existing HEPA Europe network. It was considered that an EU (rather than European) HEPA Network could be necessary
to accompany the implementation of the EU PA GL and that there was a
mutual interest and complementarity between the COM's activities and HEPA Europe: the network would need the COM for strategic guidance and for
targeted funding, while COM would need the network for expertise (e.g. several
of the most active members of the Group of Experts which elaborated the draft EU PA GL in 2007-2008 were also
members of the network), for "expert advocacy" of the HEPA concept vis-à-vis MS' authorities and for
supporting COM in the implementation of the HEPA priorities and, in the future,
the implementation of the EU PA GL. There was consensus that such a network should be a hub of
ideas. At that meeting it was agreed that a future EU HEPA network could consist of the EU members of the existing
network, and that it could hold meetings in conjunction with the annual
meetings of the existing network. Agreement was reached, at the Annual Meeting
in Bologna, in 2009, that the EU structure would be called "HEPA Europe
EU Contact Group". The Contact Group officially
constituted itself at the Annual meeting the year after in Olomouc, CZ. This first Contact Group meeting resulted in the adoption of draft
terms of reference according to which the Group's role consists inter alia of:
·                        
providing an interface between the HEPA Europe
network and the COM;
·                        
providing a common platform for the exchange of
knowledge, information, practices and approaches in relation to the promotion
of sport and health-enhancing physical activity (HEPA);
·                        
supporting the dissemination of internationally
agreed guidelines and strategies for PA policy promotion, such as the EU PA GL
(2008), (…). 
The HEPA Europe-EU Contact Group meeting in
the framework of the Annual Symposium 2012 focused more concretely on the
planned EU policy initiative. Inter alia the following comments were made
following the COM's intervention on its respective plans, including the
monitoring framework:
·                        
It was suggested to consider
the possibility of pilot testing in some MS regarding the feasibility of
the instrument (monitoring framework) - WHO Regional Office for Europe;
·                        
Regarding the cost for
implementation, it was proposed to develop on the 'cost of inaction' - British
Heart Foundation;
·                        
On the question how
monitoring could work in practice, the idea of focal points in the MS
(similar to those already existing for nutrition) was strongly supported by
several participants;
·                        
As to the possible role of
HEPA Europe, the chairman of the network suggested that capacity building
and specific training (e.g. summer schools) could be organised, for
instance relating to specific themes of the EU PA GL; moreover the HEPA Europe
conference could be an important platform for the dissemination of outcomes
from the implementation of the present initiative;
·                        
Regular reporting on the
implementation of the EU PA GL (across sectors) was considered a crucial
means to generate change;
·                        
Concerning the indicators
more particularly, the group had no questions but confirmed the importance of
keeping the indicator on 'budgets'.
Workshop on
"EU Physical Activity Guidelines - indicators"
The workshop took place on 29 February 2012 and
was organised by the COM in cooperation with the contractor that carried out
the study commissioned by DG EAC to assist with the preparation of the planned
initiative, in particular the development of a set of indicators to monitor
progress. The workshop was led by the HEPA experts in the study team and was
attended by academics and researchers with recorded experience in the field of
HEPA, as well as WHO Europe and relevant COM services (EAC, SANCO, MOVE). After
introductions by the COM (policy framework and state of play in preparing the
initiative) and by the contractor (overview on work in progress regarding the
study), the workshop focused on the proposed monitoring framework for the
implementation of the EU PA GL. A representative of the study team presented
the scientific and methodological background, i.e. outlining the
difference between process, output, outcome and impact indicators, reminding
participants of key aspects of a ‘good’ indicator, and introducing existing
efforts at national and international level to monitor HEPA policy. Several
other presentations followed, including by a representative from WHO Europe who
provided an overview of the joint COM-WHO monitoring project / database on
nutrition, obesity and physical activity (NOPA) and shared experience from
the NOPA project regarding the availability of relevant data, the process of
compiling, validating and analysing data, and other challenges. Following the
presentation, workshop participants highlighted the relevance of the NOPA
database for the proposed initiative. Key conclusions were that in order for
the planned initiative to be successful, the indicators would have to be of
interest to the MS, and it would have to be feasible for them to collect the
required data. Clarification was sought on issues such as the role of the
national focal points, the process of data validation, and the difference
between summary indicators (used in the NOPA project mainly for policy
development) and detailed indicators (used mostly for policy implementation).
Another presentation (KU Leuven) provided information on the 'study on
harmonised collection of European data and statistics in the field of urban
transport and mobility' carried out for the COM (DG MOVE). In exploring
potential synergies between HEPA indicators and urban mobility indicators, the
field of urban travel data and urban infrastructure data was highlighted.
Workshop participants agreed that data on travel patterns and in particular on
active travelling could be very relevant. However, it was noted that such data
was usually collected at the city rather than at the national level, making it
difficult to feed into a monitoring framework at MS level.
The second part of the workshop was dedicated to
the discussion of an initial list of proposed indicators to measure the
implementation of the EU PA GL in the MS. The discussion was based on the
draft indicators table provided as part of the workshop background document.
The first set of indicators discussed concerned the 'effects of the EU PA GL'
(i.e. whether they are known by relevant stakeholders and whether MS have taken
specific actions due to the EU PA GL). While many participants felt there would
be value in measuring this, others had doubts as to whether this was feasible
due to a number of conceptual, methodological and logistical concerns.
Nonetheless, it was noted that even if direct attribution was not feasible,
necessary and/or desirable, the EU PA GL and the different intervention
areas and sectors they cover provide an appropriate reference framework for
monitoring MS policies. In the area of 'International PA recommendations
and guidelines' (guidelines 1-2), most participants agreed with the indicators
proposed by the study team, although there was some discussion around whether
or not to include a specific indicator on the PA levels of children. It was
also noted that an indicator proposed under the topical area “health” on the
existence of an appropriate system to monitor PA levels in each MS (usually as
part of health monitoring) could be moved to this section. Under the heading
'Cross-sectoral approach' (guidelines 3-5), there was some constructive debate
around the phrasing and level of detail of the proposed indicators. Generally, it
was noted that ideally indicators should not be phrased as simple “Yes/No”
questions, but rather seek additional information (e.g. concerning the mandate,
capacity, resources etc. of national HEPA coordination mechanisms) that would
allow for validating the claims of MS and actually tracking progress. The study
team explained that this was the intention, and that questionnaires for data
collection would need to be drafted with this in mind. A discussion ensued
around the draft indicators for each of the different sectors at which the EU
PA GL are aimed, namely 'sport' (guidelines 6-13), 'health' (14-20),
'education' (21-24), 'environment, urban planning and public safety' (25-32),
'working environment' (33-34), and 'services for senior citizens' (35-37). Considering
the potential validity, clarity, objectivity, sensitivity, action orientation
and feasibility of each indicator in turn, the group suggested adding, amending
or deleting certain indicators. These discussions were often informed by the
relevant experiences of other projects, in particular the COM-WHO NOPA project,
which provided a good indication of MS’ ability to provide relevant data in
different areas. Finally, participants discussed the proposed indicators in the
areas of 'indicators, monitoring and evaluation' (guideline 38), 'public
awareness and dissemination' (39), and 'EU HEPA Network' (40-41). Regarding the
former two areas, there was widespread agreement on the proposed indicators,
but the experts discussed critically whether specific indicators related to the
EU HEPA Network would be appropriate.
Based on the feedback provided at that workshop
the study team revisited the draft list of indicators. Results were
subsequently further shared and discussed in the following weeks and months
with relevant groups and/or fora, including the EU Expert Group on Sport,
Health and Participation, the HEPA Europe Network, and a special workshop
during the 2012 EU Sport Forum.
9.4.        Stakeholders
and the general public 
EU Sport Forum
2012
At the EU Sport Forum 2012 (Nicosia, 20-21
September) the Commission organised a high-level panel debate for Forum
participants and EU Sport Ministers on "the contribution of sport and
physical activity to Europe's economy".[153] Sport
stakeholders inter alia called for a 'new transversal policy initiative to
promote HEPA' (President of the French Olympic Committee), noted that 'Physical
activity was important to health and to Europe's economy and politicians had
not yet managed to convince citizens', that 'the major weakness was the lack
of a cross-sectoral approach in HEPA promotion policies and here useful
documents existed at EU level, but their implementation remained patchy' and
that therefore 'better use should be made of the EU Physical Activity
Guidelines in national policies' (chairman of the Cyprus Sport
Organisation) and, commenting the results from a recent NIKE study, echoed the 'importance
of integrating physical activity in citizens' daily lives and to ensure an
early positive experience for children in this regard' (President of the
Federation of European Sporting Goods Industries).
Expert seminar on a possible EU initiative in the field
of HEPA
In the context of the EU Sport Forum 2012
an Expert Seminar on a possible new EU policy initiative in the field of HEPA
was organised on 19 September with the support from and co-chaired by the COM.
The seminar served to introduce the initiative and stimulate comment and
discussion from participants, who consisted of about 40 experts representing a
broad cross section of academe, sport stakeholders and MS officials. The
seminar began with a welcome presentation and introduction to the initiative by
the COM providing a summary of the evolution of EU sport policy and the
underlying policy context. Representatives from the study team (study to
support preparations of the COM proposal in the field of HEPA) made a basic
introduction to the concept of Impact Assessment. In the discussion participants
were favourable towards the new initiative and considered how would work in
practice. A considerable number of participants stressed the need for the
monitoring mechanism to gather comparable and consistent data. Several
experts then added that this could be achieved in part by encouraging the MS to
adopt either the International Physical Activity Questionnaire or the Global Physical
Activity Questionnaire. Part of the discussion also centred on the nature of
the problem – whether Europeans choose to be physically inactive or whether
the default options they face do not present adequate opportunities to engage
in PA, why some countries have had more success than others in implementing
the GL and how improvements might be achieved in the future. The study team
then presented the potential monitoring mechanism of the new initiative and the
set of proposed indicators that would be used to gauge progress. In particular,
it was explained that the monitoring mechanism should consist of a medium
number of (quantitative) indicators (at that time: 26), based on a
combination of different methods and focused on the thematic areas of the EU PA
GL, rather than all 41 Guidelines. Such an approach would strike a balance
between exhaustiveness and flexibility and the need for the MS to play a large
role in the data collection. Participants expressed favourable views of the
indicators, with questions focused on the nuance of specific indicators and the
importance of using the limited set of indicators to capture as much relevant
information as possible. The COM acknowledged that the proposed set of indicators
was still in draft stage and would be finalised on the basis of participants’
comments and further work in cooperation with experts in the study team.
EU Platform for
Action on Diet, Nutrition and Physical Activity
This EU Platform is a forum for European-level
organisations, ranging from the food industry to health, consumer and sport
NGOs, allowing its members to agree commitments on tackling current trends
in diet and physical activity. The Platform meets 3-4 times per year. Since
the inception in 2005, at least one of these annual meetings included physical
activity promotion as its main topic. There have also been separate meetings on
sport, and in September 2007, a separate Platform workshop was focusing on
physical activity promotion. In addition, COM (EAC) presented its activities in
the field of sport to the Platform in 2005, 2006, 2008 and 2011. The Platform
charter[154]
outlines the possible fields of action for Platform members, and promotion of
physical activity is one of six such fields.
The Platform currently has 33 members, of which 5 have sport
and HEPA as their main focus (European Confederation Sport and Health; European
Cyclists' Federation; European Health and Fitness Association; European
Non-Governmental Sports Organisation; the International Sport and Culture
Association).[155] 
There are 30 (out of a total of 255) commitments
registered in the Platform database with physical activity promotion as their
main type of activity; of these 17 (out of a total of 122) are active now
(13.9% of all active actions), and four of these are new commitments, running
from 2012 and onwards. 
Following the 5 year evaluation report of the Platform,
where it was stated that: "the physical activity area being less
represented and considered in the Platform…", renewed objectives for
the Platform were defined and adopted at the Platform plenary meeting in
February 2011. In the working document on renewed objectives[156] physical activity and sport
were stated as one out of five priority areas and target groups for Platform
commitments for 2011-2013. The Platform evaluation report also states the
following regarding repartition per sector of Platform members in its
conclusions: "That said, the education sector is not represented at all,
in spite of the importance of the ‘Lifestyles and education’ area which
accounted for more than half of the Platform’s active commitments as at January
2010 (see EQ 2.2). While the physical activity sector was perceived by a
number of members as being under-represented, this sector is in fact
represented by six Platform members (18% of the total), 336 sub-members (the
third largest group) and 12 active commitments (the fourth largest group).
Therefore, the perceived lack of representation of this sector by members may
be due more to its lack of visibility than an actual
under-representation."
Sportvision 2012 (DK Presidency)
The main stakeholder event organised by the International Sport and Culture Association (ISCA) on behalf of the
DK Presidency in the field of sport was a Conference focusing on sport for all
(Sportvision2012), which took place in Copenhagen on 19-20 March 2012. It inter
alia focused on "sport and health" and was an opportunity to test the COM's ideas and seek feedback on the planned
policy initiative in the field of HEPA. The event gathered around 400
participants from 35 countries; non-governmental sport stakeholders, academics,
representatives from MS' sport departments. After high-level interventions,
including from the Commissioner who highlighted the importance of sport for all
in the EU level debate on sport and mentioned the COM's activities and plans in
the field of HEPA, the following statements were made in the discussion: "Promoting
PA is the best buy in public health."; "There is evidence that PA
improves health, better health increases economic growth, physical inactivity
is costly (micro studies) and increasing PA increases economic growth (macro
studies)."; "There is a paradox of increased awareness about the
positive effects of PA on the one hand and declining participation rates on the
other."; "The sport sector should realise its potential
and take account of the need to meet new demands."; "Further
impetus from the EU level to promote participation and PA, including a possible
policy initiative, would be welcomed."
Public (online)
consultation
In
preparation of its proposals to implement the new Treaty provisions for sport,
the COM has carried out broad consultations with all concerned parties, the
centrepiece of which was an online consultation in the first half of 2010
(2/4-2/6) which was a success as more than 1,300 valid submissions were
received. Approximately 30% of respondents filled out the questionnaire on
behalf of their organisations[157]. This ratio demonstrates that the online
consultation reached a considerable number of respondents outside organised
sport. 
The
objective of the public consultation was twofold. Firstly, it aimed at
gathering stakeholders' views on the key challenges for sport in Europe.
Secondly, it intended to help the COM identify priority areas for action at EU level. In parallel to the online
consultation, the COM received written contributions in the form of 50 position
papers from stakeholders. Both parts of the
consultation contained a number of questions on HEPA with direct relevance
for the planned EU policy initiative. 
A Report was
prepared that described the consultation process and analysed the contributions
received.[158]
It provided an overview of the wide range of suggestions and the diversity of
opinions expressed in the course of that process. The quantified results of the
online questionnaire relating to physical activity and the analysis referred to
hereafter are reflected in the report from the consultation.
 Assessment points conversion table 
 Field value || Corresponding relative value 
 Strongly agree || 3 
 Agree || 2 
 Tend to agree || 1 
 Don't know || 0 
 Tend to disagree || -1 
 Disagree || -2 
 Strongly disagree || -3 
I) Part one of the questionnaire ('Key challenges for
sport in Europe') included 10 (out of 47) questions which can be directly
related to physical activity / HEPA or which have relevance for the planned
initiative (e.g. data collection): Q1, 2, 3, 4, 5, 6, 7, 15, 28, 36. 
·                        
The practice of sport and physical activity is
not sufficiently supported by public authorities (Q1);
·                        
The practice of sport and physical activity is
not sufficiently supported by sport organisations (Q2); 
·                        
Sport organisations concentrate too much on
competitive sports at the expense of non-competitive activities and health-enhancing
physical activity (Q3); 
·                        
There is not enough sport and physical activity
in primary and secondary education (Q4);
·                        
There is not enough sport and physical activity
in higher education (Q5);
·                        
Too many obstacles (e.g. physical obstacles,
availability, expenses) exist to accessing sporting activities and facilities
(Q6);
·                        
There are unequal possibilities to access
sporting activities and facilities between different socio-economic groups
(Q7);
·                        
There is not enough comparable data on the
economic and social impact of sport in EU Member States (Q15);
·                        
There is not enough communication among
different EU Member States regarding different approaches they have in relation
to sport and sport policy (Q28);
·                        
Public funding for grassroots sport is not
sufficiently stable (Q36).
Figure 1: Physical activity promotion in
education, by public authorities and by sport organisation
On all these
questions, respondents either 'strongly agreed', 'agreed' or 'tended to agree'.
Concerning
these key challenges for the EU in the field of sport, the
report noted inter alia that "Replies to questions 4 and 24 represented
the highest cumulative value, highlighting public concern about insufficient
presence of sport and physical activity in education (all levels). This was
confirmed by a number of position papers."
II) Regarding the second part of the
questionnaire ('Identifying policy priorities for EU action'),
respondents 'strongly agreed' or 'agreed' that the EU should:
·                        
support the role of sport in enhancing public
health through PA (Q. A1);
·                        
promote sport and PA as a tool to achieve a more
active lifestyle and to fight obesity (Q. A2);
·                        
encourage EU MS and sport organisations to take
action in order to increase participation levels in sport and PA (Q. A3);
·                        
promote sport for all (Q. A9);
·                        
promote knowledge-based decision making (Q.
A13);
·                        
collect and analyse comparable statistical data
on the impact of sport in economic and social terms (Q. A14);
·                        
foster coordination and cooperation among MS,
sport organisations and other actors in the field of sport (Q. A21):
·                        
pursue a better balance between the societal and
commercial dimensions of sport (Q. A29). 
The promotion of PA and the need for more
evidence on sport and PA (i.e. weighted average relative values > 2),
together with social inclusion, the fight against threats to sport and topics
relating governance issues, clearly could be identified as those areas where the
public wishes the EU to play a role and to become active. Accordingly, the
report notes that "A considerable number of respondents referred to the
fact that there were a number of tasks that the EU could do in relation to the
social and educational functions of sport. Support and promotion of sport as
a health-enhancing activity ranked particularly high in the replies."
The importance of EU action in the field
of HEPA was furthermore underlined in the position papers submitted on
behalf of 'organisations' in the framework of the consultation process.
The report concludes that the public
consultation based on the online questionnaire and the written contributions
served as an important source of information to give indication regarding priority
areas for future EU action. Among the four areas receiving the highest
degree of attention from the general public and stakeholders the summary report
mentions 
·                        
promotion of the social and educational
functions of sport, including health-enhancing PA, ..., participation
levels in sport, ..., sport for all. 
Among the three horizontal priorities the
report identified as a main area
·                        
support for knowledge-based decision-making
in the field of sport.
10.         ANNEX
II: ADDITIONAL EVIDENCE ON PHYSICAL ACTIVITY IN THE EU
10.1.      The
benefits of physical activity and detriments caused by physical inactivity
The WHO has recently identified
insufficient physical activity as the fourth leading risk factor for premature
mortality and disease globally[159],
being responsible for about 1 million deaths per year in the European Region
alone. Overweight and obesity, among the most visible effects of insufficient
physical activity, have tripled in many countries in the WHO European Region
since the 1980s, and the numbers of those affected continue to rise at an
alarming rate, particularly among children. Physical inactivity also plays a
role in a host of health problems aside from obesity. According to the
WHO, it is estimated to cause around 21-25% of breast and colon cancers, 27% of
diabetes and about 30% of ischaemic heart disease.[160]
Physical activity’s role in development has also been demonstrated, as research
has shown direct links between adolescent inactivity and overweight and obesity
and related diseases, breast cancer and bone health in later life.[161] Overall, the WHO estimates that people who are insufficiently
physically active have a 20-30% increased risk of all-cause mortality compared
to those who engage in at least 30 minutes of moderate intensity physical
activity on most days of the week.[162]
Also the mental health effects of
physical activity, including sport and exercise, are well documented and
recognised, including in a range of scientific publications.[163] Physical exercise improves
mental health, helps prevent depression and helps to
promote or maintain positive self-esteem.[164]
People who regularly engage in physical activity show better health outcomes,
including better general and health-related quality of life, better functional
capacity and better mood states.[165]
Some studies have found significant positive relationships between physical activity and cognitive outcomes.[166] Studies
on the relationship of physical activity and stress underline that physical
activity plays a key role in the control of the body's response to physical stress
and prevents telomere shortening.[167]
Results from an EU study on mental health and physical activity indicated a positive relationship between physical activity level
and mental health for population subgroups.[168]
In light of all these benefits, physical
activity has been identified as the ‘miracle drug that can benefit every
part of the body and substantially extend lifespan’.[169] 
Conversely, physical inactivity puts a
burden on society through the hidden and growing cost of medical care
and loss of productivity.[170]

Obesity has been estimated to account for
2-8% of public health costs in different parts of Europe.[171] Factoring in other diseases, the
total cost of physical inactivity is certainly much higher, and likely to
increase even further due to the ageing population. In addition, physical
inactivity also brings with it significant indirect economic costs, including
the value of economic output lost because of illness, disease-related work
disabilities and premature death.[172]
For example, a study based on three Dutch
databases[173] found that workers who engage in vigorous physical activity at
least three times per week had significantly less sick leave (up to four days
per year). Similarly, a recent Danish study[174]
calculated that in Denmark, 3.1 million days of sick leave each year are
attributable to physical inactivity, which is equivalent to approximately 1.1
days per worker. The cost of the production loss from sickness and early
retirement due to physical inactivity to the Danish economy was estimated at
between EUR 400 and 900 million per year, equivalent to between 0.2% and 0.4% of GDP.[175] 
The costs due to physical inactivity (health care
costs, economic output forgone due to illness and morbidity, sick leave and
pre-mature death) in England that the Impact Assessment uses as a basis to calculate
economic benefits amount to €61 per inhabitant (chapter 5.2). While
figures are not directly comparable, this can be seen as
a realistic basis for the calculation, as in other countries studies estimated
a similar or higher amount. In Hungary[176] all physical
inactivity-related diseases were assessed to cost €1.1bn in 2009 (283.5bn HUF,
exchange rate 1EUR/265HUF), or €110 per inhabitant (population 10 million). A
study on the cost of physical inactivity in Australia[177] estimated direct health expenditure of about €0.93bn ($1.5bn,
exchange rate $1/0.62EUR) in 2006 attributable to physical inactivity, or €46
per inhabitant (population 20.4 million). In Switzerland[178] insufficient physical activity is responsible for direct and
indirect costs of €1.63bn (2.4bn CHF, exchange rate 1CHF/0.68EUR in 2003), or
€223 per inhabitant (population 7.3 million in 2001). According to a Norwegian
study in 2002, the cost of inactivity including medical treatment costs and to
a varying degree production losses and loss of welfare amounts to 980 Euro per
person per year.”[179] In Austria[180] costs
(including direct costs in healthcare, work absence, early retirement, pension payments) of €3.3bn were estimated
for 2010 due to physical inactivity, or €393 per inhabitant (population 8.4
million).[181]
In light of the above, according to
experts, the issue of physical inactivity is being described as “pandemic,
with far-reaching health, economic, environmental and social consequences”
(The Lancet series Volume 380, Issue 9389, of 21 July 2012).
10.2.      The
persistent lack of physical activity in the EU
The rates of physical inactivity in the
EU remain alarmingly high. The available data shows that the vast majority
of Europeans do not engage in sufficient HEPA, a trend that has not shown much
improvement in general terms.
Already in 2003, an EU-wide survey on
physical activity showed that 41% of EU-15 residents had not engaged in any
moderate physical activity (which includes e.g. carrying light loads,
cycling at a normal pace) in the last seven days, and 57% reporting they had
not engaged in any vigorous physical activity (which includes e.g.
lifting heavy things, digging, aerobics or fast cycling).[182] When the survey was repeated in 2006, the results were very
similar; the proportion of those who had not undertaken any moderate
physical activity remained unchanged at 41%, although there was a small
improvement in vigorous activity (with the proportion of those who had
not undertaken any vigorous activity going down to 54%).[183] 
More recent EU-wide data focusing
exclusively on physical activity does not exist, but similar surveys on
sport and physical activity suggest that the overall trend remains
unchanged. In an EU-wide survey taken in 2004, for example, 53% of respondents
claimed to exercise or play sport seldom (i.e. less than once per week)
or never, a figure that even grew to 60% of respondents by 2010.[184] The latest survey also demonstrates vast discrepancies between
individual Member States. In Sweden and Finland, more than 70% of respondents
‘exercise or play sport’ regularly or with some regularity (i.e.
at least once per week), while in Greece and Bulgaria the figure is below 20%. 
The graph below illustrates these
disparities by highlighting the prevalence of lacking physical activity in all
Member States. It demonstrates that the countries with the highest
inactivity rates are all in Southern and Eastern Europe.[185] 
Figure 1: Europeans claiming to
exercise ‘seldom or never’
Source: Eurobarometer 334 Sport and Physical Activity
(QF., page 10)
The differences between countries are also
confirmed by a European survey carried out in 2010[186] addressing several aspects of
the health of European Citizens. Physical activity patterns were looked at within
the chapter "Healthy Life Style Awareness and Practice" that inter
alia investigated particular occasions when people could get physical exercise.
The level of activity varies with the occasion, and strong contrasts occur
between countries. Activity is done by over 50% of Europeans: When on the
go – going from one place to another; and When "in and around the
home". But only a minority of Europeans claim to exercise as part of their
recreational activities (about 40% having "some" or "a lot"
/ decreased since 2006), consciously dedicating some free time to exercising; and
scores are even lower for activity at work. Results suggests that exercising
for its own purpose – during recreational activities – is not improving, and
remains a hobby for the wealthier social classes, as well as for young people.
The above Eurobarometer survey illustrates
that lack of leisure-time physical activity tends to be more common in the
lower socio-economic groups – these people tend to die at a younger age and to
have, within their shorter lives, a higher prevalence of all kinds of health problems.
The above survey indeed suggests that socioeconomically disadvantaged groups,
such as early school leavers and people with financial problems, are far more
likely to be physically inactive: 64% of people who had left the education
system by the age of 15, and 56% of those who have trouble meeting financial
obligations, never exercise or play sport (compared to 35% of Europeans who
never have difficulty meeting financial obligations).
Regarding the elderly, a 2012 Special
Eurobarometer on active ageing[187] highlights
that although the majority of respondents believes their country and local area
are “age-friendly”, most agree that it could be improved with regard to
facilities for older people to stay fit and healthy (42%). In general, respondents
from Southern countries and new Member States (e.g. CY 65%, EL 55%, SK 61%, SI
59%) stressed the lack of facilities as the main improvement most needed in their
local area. 
With regard to children's
participation in daily physical activity, evidence suggests that many children
do not meet the recommended guidelines of at least 60 minutes of
moderate-to-vigorous physical activity daily[188]
Some of the factors influencing the levels of physical activity undertaken by adolescents
include the availability of space and equipment, the child’s present health
conditions, their school curricula and other competing pastimes. Only
one-in-five children in EU Member States report that they undertake
moderate-to-vigorous exercise regularly[189], according
to results from the 2009-10 HBSC survey. It is of concern that physical
activity tends to fall between ages 11 to 15 for most European countries. Daily
moderate-to-vigorous physical activity for 2005-06 and 2009-10 averaged across
21 EU Member States has decreased for both boys and girls, and in all age
groups, except boys aged 15 years.
National data on HEPA rates serves both to confirm such general trends,
and also to highlight the significant differences between Member States.
Because surveys are conducted using different methodologies, asking different
questions under different timeframes, it is not possible to compare nationally
generated physical activity data directly.[190]
However, a look at data from individual countries reveals some interesting
trends, in particular that some Member States have made considerable progress,
while many others have made none or even regressed.
For
example, a joint health monitor project in the Baltic States and Finland
showed that, between 1998 and 2008, “Leisure-time physical activity and
commuting physical activity have remained nearly at the same level for 10 years
in all of the Baltic countries [Estonia, Latvia and Lithuania]. Finland was the
only country where some increase in the level of leisure-time physical activity
was found from 1998 to 2008.”[191] (See
the table hereafter.)
Figure 2: Evolution of leisure-time
physical activity in Finland and the Baltic States 
Trends of age-standardised prevalence of
those who exercised twice a week or more in leisure time from 1998 to 2008;
average of men and women (%). Source: FINBALT
Regular
surveys in England reveal a significant increase in the proportion of
those who meet government recommendations for the minimum level of physical
activity to achieve health benefits, from 27% in 1998 to 36% in 2008.[192] The number of those meeting government recommendations for HEPA in Ireland
has also risen slightly, from 38% in 1998 to 41% in 2007.[193] In France, a study carried out in 2000 and in 2010 for
people aged 15-75 identified a modest increase in the participation rates for
almost all ‘families of activities and activities’ (including walking,
swimming, gymnastics, cycling).[194]
However, in Italy the proportion of the population that meets the
minimum recommended physical activity levels stagnated between 2007 and 2009
(at 33%), and the percentage of those who are classified as “sedentary” (and
undertake no physical activity at all) has even increased slightly, from 28% to
30% of the population.[195] While this data is not directly comparable across countries[196], it provides a clear indication that some Member States have had a
degree of success in achieving increases in physical activity, while policy in
many others has failed to produce the desired results. 
Examples
from different EU Member States show indeed that there are successful
interventions and practices to learn from.[197] This is inter alia also
reflected in the EU Physical Activity Guidelines that showcase best practice
examples from the national level for each of the guidelines themes (i.e. sport,
health, education, transport, environment, urban planning and public safety,
working environment and services for senior citizens).[198] There are many other sources
referring to efficient interventions in EU Member States focusing on specific
target groups (e.g. youth[199],
elderly people[200]).
11.         ANNEX
III: MONITORING FRAMEWORK AND PROPOSED TABLE OF INDICATORS
11.1.      Introduction
This annex contains two elements:
·                        
An overview of
indicators proposed for the monitoring of the implementation of the EU Physical
Activity Guidelines as an element for a future Commission initiative on HEPA;
·                        
Additional information on the main existing information sources, databases and publications for a
future monitoring framework.
This work was prepared by the study team,
i.e. Economisti Associati srl (Lead Firm), The Evaluation Partnership
(Partner), University of Zurich (sub-contractor), VU University Medical Center,
Amsterdam (sub-contractor), and has been discussed at the EU expert and policy
levels (see also Annex I "Consultations").
11.2.      Identifying
indicators to monitor the implementation of the EU PA GL (in line with the
preferred policy option in the IA)
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[201]: 
·                        
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 programs, 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. 
The aspect of possible impacts of the EU PA
GL are already addressed in the main part of the IA 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. 
Indicators are a commonly used tool to
assess the process and results of policies and programmes. It is therefore
important to bear in mind the key principles for a “good” indicator, including[202]: 
·                        
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
Overview
of work carried out
The first step
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 and expectations
and concerns regarding the foreseen 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. 
The main aim of the second step was to
define the scope, objectives and expected results of the evaluation of the
implementation of the EU PA GL. 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 the work, three possible approaches to develop indicators for the monitoring
of the EU Physical Activity Guidelines were identified: 
(3)                   
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
(4)                   
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.
(5)                   
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 MS actions to the EU
PA GL as foreseen in approach 1) would have faced a number of conceptual,
methodological and logistical difficult and in addition was not considered a
priority of the Commission. With regard to approach 3), it was considered
unlikely that all EU MS would implement all 41 sub-guidelines of the EU PA GL
universally as their political priority setting, cultural approach to HEPA
promotion and available resources would lead to a different priority setting.
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 which 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 3) was
considered both impractical and methodologically problematic. 
Therefore, it was decided to develop
indicators on thematic areas of the EU PA GL as proposed in approach 2),
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. This approach
was the basis for the preferred policy option (Option C) in the Impact
assessment.
The third step of the work aimed at
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 will be an important aspect to be considered,
and new indicators will be defined were appropriate. The proposed list of
indicators was developed with the input of experts and consulted in expert
fora, with the policy level and with stakeholders.
Amended
versions of the list of proposed indicators were presented and discussed at the
following meetings: 
·                        
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[203]
·                        
Expert seminar at EU Sport Forum 2012 in Cyprus,
19 September 2012
The comments
received were taken into account in the further development of the proposed
list of indicators. 
Indicator
ideas which were not included into the proposed framework
The reasons
are laid down hereafter.
·                        
Indicators on the directly attributable
effects of the EU PA GL (e.g. knowledge on its
existence, specific actions taken as a direct consequence etc.) 
It was not deemed necessary to assess
attribution, but it was decided that the framework should focus on assessing
actions, which were in line with and inspired by the directions of the EU PA
GL. 
·                        
"Sport for all” addressed in existing
national HEPA policies
This indicator idea was not deemed feasible, as
it would have required a content analysis of national HEPA policies. In
addition, the other proposed indicators on this topic were deemed more useful
and feasible. 
·                        
Programmes to increase traffic safety for
pedestrians and cyclists
Even though the topic was deemed an important
one, such an indicator was not regarded as being feasible to implement in the
near future. 
·                        
Expansion of green spaces and play areas in
urban areas
Assessment of data availability revealed
limited feasibility at this time. 
·                        
Expansion of cycle and walking lanes
Assessment of data availability revealed
limited feasibility at this time and consultation showed concerns regarding
assessing infrastructure. 
·                        
Promotion of better urban design to provide
safe and attractive structures everyday physical activity, cycling and walking, e.g. through Healthy Urban Planning or indicator on Health Impact
Assessments and whether they include active transport aspects
Based on initial findings of a study on behalf
of DG MOVE on “Harmonised collection of European data and statistics in the
field of urban transport and mobility”, the necessary data on such indicators
would not be available. Albeit considered important, they were therefore not
included into the proposed list of indicators on grounds of limited
feasibility. 
·                        
Awareness raising campaign as integrated part of
an overarching national HEPA promotion strategy
The more generic indicator on the existence of
an awareness raising campaign was deemed more useful and feasible. 
·                        
Inclusion of vocational training as a further
category to indicator no. 14 (Physical education in primary and secondary
schools)
Not included as other forms of tertiary level
education are also not included and formal vocational training does not exist
in many EU countries. 
In addition, two proposed indicators on the
guidelines no. 40 and no. 41 on an EU HEPA network (namely whether annual
meetings take place and whether stable financial support was available for the
HEPA Europe – EU Contact Group) were removed from the indicators table as it
was felt they were not relevant for Member States and were more appropriately
addressed by internal reporting; in this sense they would remain part of the
monitoring framework but would not be listed in the indicators table. 
In the final review of the proposed
indicators table, three indicators ("Concerted action of national,
regional and local level", "Funding allocated to HEPA-specific
research", "National alliance for physical activity promotion amongst
sedentary older people"), despite their value for evaluation of policies,
were removed, because of the limited sources and in an effort to decrease
administrative burden.
11.3.      Overview
of proposed 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 GLs 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. 
In the section following the table, the
proposed methodology for each indicator is described. Key data sources are
presented in more detail in chapter 3. 
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 || WHO global health data observatory or European Health Interview Survey (EHIS) 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/Commission 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/Commission 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/Commission 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/Commission 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/Commission 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/Commission 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/Commission 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/Commission 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/Commission 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/Commission 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/Commission 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.
11.4.      Operationalization,
methodology and data by proposed 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 11.5. 
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/Commission 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). 
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[204] 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.[205]
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) [website]. 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).

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).
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/Commission 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/Commission 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 the 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/Commission
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). 
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). 
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/Commission 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 27 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/Commission
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).
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.

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/Commission 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/Commission
Project on “Monitoring progress on improving nutrition and physical activity
and preventing obesity in the European Union”. Copenhagen, WHO Regional Office
for Europe, 2009. 
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/Commission 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/Commission 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).
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/Commission 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/Commission 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/Commission
Project on “Monitoring progress on improving nutrition and physical activity
and preventing obesity in the European Union”. Copenhagen, WHO Regional Office
for Europe, 2009.
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/Commission 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/Commission
Project on “Monitoring progress on improving nutrition and physical activity
and preventing obesity in the European Union”. Copenhagen, WHO Regional Office
for Europe, 2009. 
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/Commission
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/Commission 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/Commission
Project on “Monitoring progress on improving nutrition and physical activity
and preventing obesity in the European Union”. Copenhagen, WHO Regional Office
for Europe, 2009. 
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: 
(c)                     
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. 
(d)                   
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 2011/2012. The
absolute has also been covered in the framework of a joint WHO/Commission
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/Commission 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. The next edition will be published for the
academic year 2012/2013.
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/C Project on
“Monitoring progress on improving nutrition and physical activity and
preventing obesity in the European Union”. Copenhagen, WHO Regional Office for
Europe, 2009. 
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: 
(e)                     
active school breaks
(f)                     
active breaks during school lessons
(g)                   
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).
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. 
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/Commission
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.
Geographic and
temporal coverage
The WHO/Commission 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/Commission
Project on “Monitoring progress on improving nutrition and physical activity
and preventing obesity in the European Union”. Copenhagen, WHO Regional Office
for Europe, 2009. 
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/Commission
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/Commission 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/Commission
Project on “Monitoring progress on improving nutrition and physical activity
and preventing obesity in the European Union”. Copenhagen, WHO Regional Office
for Europe, 2009. 
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 Commission 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. 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 the 27 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 27 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). 
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).
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/Commission
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/Commission
Project on “Monitoring progress on improving nutrition and physical activity
and preventing obesity in the European Union”. Copenhagen, WHO Regional Office
for Europe, 2009. 
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/Commission
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/Commission 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/Commission 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. 
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)
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[206])

Data sources
Information on this indicator has been
collected in 2009 and 2010 through a joint WHO/Commission 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).
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/Commission 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/Commission 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/Commission
Project on “Monitoring progress on improving nutrition and physical activity
and preventing obesity in the European Union”. Copenhagen, WHO Regional Office
for Europe, 2009.
11.5.      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/Commission 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 Commission 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. 
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[207] (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 until now been negotiated between the WHO and the European Commission (DG
SANCO). In some cases, the National Information Focal Persons 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 national HEPA co-ordinators.
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[208]. 
For Europe, Daugbjerg et al.[209] 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[210]. 
·                        
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[211].

·                        
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)[212].
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.
12.         ANNEX
IV: DIAGRAM (PHYSICAL ACTIVITY MONITORING UNDER A RECOMMENDATION ON HEPA, AS OF
MID-2014)
13.         ANNEX
V: COSTS TO THE EU BUDGET AND ADMINISTRATIVE COSTS IN THE MEMBER STATES
13.1.      Costs
to the EU budget
Option A:
Under the baseline scenario, meetings with Member State
representatives will continue to be organised at EU level with financial
support from the COM. Currently, on average, the Expert Group on Sport, Health
and Participation (XG SHP), meets 3 times per year (corresponding to
approximately EUR 84,000 per year). This adds up to EUR 532,000 / 28 MS for six
years assuming that meetings will start in the second half of 2014.
Option B:
No additional costs for the EU budget would be incurred as compared
to the baseline scenario.
Options C and D:
Regarding
options C and D, the additional costs for the EU budget, as compared to the
baseline scenario, have been calculated taking account of
–                        
the on-going project entitled "Monitoring
the implementation of the European Strategy for Nutrition and Physical Activity
jointly with WHO (NOPA II)", introduced through the EU contribution
agreement with the WHO[213],
which has a duration of two years (until mid-2014);
–                        
consultations with HEPA Europe experts who
provided advice with regard to costs to be expected for support for action in
the Member States (e.g. support for countries to identify priority action
areas, country assessments, training of HEPA focal points).
An estimated
break down of the expected costs for the EU for the implementation of the
planned initiative, notably the support mechanism for the Council Recommendation
on HEPA, would be related to two areas:
(h)                     
monitoring of the implementation of the EU PA
GL and
(i)                     
support for action / implementation at
national level through a country-specific situation
analysis to identify priority areas for action and related capacity building.
In area a), regular surveys will be
carried out using standardized questionnaires and reporting tools, based on the
EU PA GL monitoring framework (set of indicators) and the planned national HEPA
focal points. The information will be verified and included into the WHO NOPA
Database (http://data.euro.who.int/nopa/). The database will be adapted so as to facilitate the production
of ad-hoc snapshots of implementation levels in individual Member States, using
the EU PA GL monitoring framework. Such reports would be delivered to the
Commission at regular intervals to form part of the reporting activities on the
Council Recommendation.
The main outcomes would be as
follows:
–                        
National HEPA focal points trained in applying
the Monitoring Framework;
–                        
Up-to-date information system on the level of
implementation of the EU PA GL including good practices;
–                        
Regular reports (country snapshots) to the
Commission on the national implementation level of the EU PA GL according to
the Monitoring Framework.
For option C, this would lead to the
following activities and costs for the entire MFF period:
 Option C: Activity || Costs || Timeline (year) 
 1. Coordination, data collection, validation and updating of the NOPA database with data from the monitoring of the EU PA GL || EUR 532,000 || 1-7 
 2. Technical maintenance and programming of NOPA database || EUR 175,000 || 1-7 
 3. Development of capacity building material on Monitoring Framework for meeting under activity 4 below || EUR 20,000 || 1 
 4. Two meetings of national HEPA focal points from 28 Member States on capacity building for the national application of the monitoring framework || EUR 60,000 || 1-7 
 5. Collection of good practices of country level implementation of the EU PA GL (to be included in the NOPA database in addition to the monitoring framework data) || EUR 50,000 || 1-7 
 Total 2014-2020 || EUR 837,000 ||   
Under option D the complex mechanism
to monitor the implementation of the EU PA GL by using a more comprehensive set
of indicators will result in additional costs regarding activities 1, 2 and 3.
This is, to a large extent, explained by the bigger volume of the data.
 Option D: Activity || Costs || Timeline (year) 
 1. Coordination, data collection, validation and updating of the NOPA database with data from the monitoring of the EU PA GL || EUR 784,000 || 1-7 
 2. Technical maintenance and programming of NOPA database || EUR 210,000 || 1-7 
 3. Development of capacity building material on Monitoring Framework for meeting under activity 4 below || EUR 30,000 || 1 
 4. Two meetings of national HEPA focal points from 28 Member States on capacity building for the national application of the monitoring framework || EUR 60,000 || 1-7 
 5. Collection of good practices of country level implementation of the EU PA GL (to be included in the NOPA database in addition to the monitoring framework data) || EUR 50,000 || 1-7 
 Total 2014-2020 || EUR 1,134,000 ||   
Area b) will
take account of the fact that the implementation of the EU PA GL varies
significantly across the EU. As such, support to national action on PA needs to
take into account the context of each MS and should be provided on a voluntary
basis upon request. Support for the MS is proposed to take place in 2 phases:
(I) situation analysis and identification of priority action areas (i.e.
analysis of current policy development and implementation levels on PA and
derivation of areas that require action) and (II) capacity building of national
focal points on HEPA policy development and implementation at national level,
addressing the priority action areas identified in phase I. Both phases would
be supported through the expertise available in the HEPA Europe network, build
on existing tools (e.g. WHO's HEPA Policy Audit Tool), and would be fully
aligned with the proposed new monitoring framework (as explained in Annex III
for the preferred option C). The existing annual meetings of HEPA Europe could
stimulate relevant exchange between the scientific and policy-making levels by
bringing together the HEPA Europe network and the national HEPA focal points.
The main outcomes are expected be as
follows:
–                        
Situation analysis tool for countries to
identify priority action areas;
–                        
Country assessments of the level of
implementation of the EU PA GL (10 countries);
–                        
Training package for capacity building on
implementing EU PA GL at national level;
–                        
Trained national PA focal points on implementing
EU PA GL.
This would lead to the following activities
and costs for the entire MFF period:
 Option C: Activity || Costs || Timeline (year) 
 1. Support to HEPA Europe: meetings of the Steering Committee (SC) and annual meetings to bring together science and policy levels and present the tools and activities of phases I and II to Member States, i.e. support participation of 28 MS (incl. EU Contact Group) || EUR 372,000 || 2-7 
 2. Development of tool for situation analysis and identification of priority action areas (see activity 3 below), based on existing tools, such as the HEPA PAT, and adapted to the Monitoring Framework and aligned with the capacity building modules (see activities 4 and 5 below) || EUR 55,000 || 1 
 3. Situation analysis and identification of priority action: initial assessment of policy situation in MS to identify priority action areas (max. 12 countries) || EUR 300,000 (EUR 25,000 per country)   || 1-7 
 4. Development of capacity building course material (concept, training modules and teaching plan) on national PA policy development and implementation || EUR 180,000 || 1 
 5. Organisation of annual capacity building workshop (5 days) for national HEPA focal points (to address the priority action areas identified in activity 3 above) || EUR 654,000 || 2-7 
 6. Steering committee (10 persons) on support for action in Member States: 3 meetings to address structure of training material, scope of modules, identification for evidence for action || EUR 30,000 || 1-7 
 7. Staff time for coordination of activities 1 - 6 above || EUR 252,000 || 1-7 
 TOTAL 2014-2020 || EUR 1,843,000 ||   
Under option
D, tasks for the Member States to comply with the Recommendation will
be more demanding, not least because of the requirement to report on progress
to the EU level in promoting HEPA and to reach the benchmarks and targets
agreed and set by the Council. Accordingly, the support which is proposed to be
provided to national action on PA needs, in particular the training of national
HEPA focal points will have to be more substantial. Additional costs would
occur under this option, as follows:
 Option D: Activity || Costs || Timeline (year) 
 1. Support to HEPA Europe: meetings of the Steering Committee (SC) and annual meetings to bring together science and policy levels and present the tools and activities of phase I and II to Member States, i.e. support participation of 28 MS (incl. EU Contact Group) || EUR 372,000 || 2-7 
 2. Develop tool for situation analysis and identification of priority action areas (see activity 3 below), based on existing tools, such as the HEPA PAT, and adapted to the Monitoring Framework and aligned with the capacity building modules (see activities 4 and 5 below) || EUR 65,000 || 1 
 3. Situation analysis and identification of priority action: initial assessment of policy situation in MS to identify priority action areas (max. 16 countries) || EUR 400,000 (EUR 25,000 per country)   || 1-7 
 4. Development of capacity building course material (concept, training modules and teaching plan) on national PA policy development and implementation || EUR 200,000 || 1 
 5. Organisation of annual capacity building workshop (5 days) for national HEPA focal points (to address the priority action areas identified in activity 3 above) || EUR 654,000 || 2-7 
 6. Steering committee (10 persons) on support for action in Member States: 4 meetings to address structure of training material, scope of modules, identification for evidence for action || EUR 40,000 || 1-7 
 7. Staff time for coordination of activities 1 - 6 above || EUR 504,000 || 1-7 
 TOTAL 2014-2020 || EUR 2,235,000 ||   
The following total costs
would occur for the EU budget for the MFF period:
–                        
General budget:
for all options an estimated EUR 532,000 for the organisation of meetings (e.g.
Expert Group meetings), including reimbursement of travel costs;
–                        
Sport Chapter in Erasmus+ 2014-2020:
·              
Option C: EUR 2,680,000 EUR
·              
Option D: EUR 3,369,000 EUR
13.2.      Administrative
costs in the Member States
On the following pages, the calculation has
been made (using the EU Standard Cost model) to assess the administrative costs
(burden) in the Member States for the first year and for second (+ subsequent)
years of the implementation of the planned initiative. These costs relate above
all to the reporting requirements to the EU level and thus apply in particular
to options C and D (new monitoring framework including set of indicators) and,
to a lesser extent, also to option B (provision of regular updates on the
implementation of the EU PA GL to the EU level). No costs would be incurred for
option A. For the preferred option C, the total administrative cost per MS for
the period 2014-2020 is expected to amount to roughly 47,300 EUR. This is based
on the calculation that the average cost per MS would amount to roughly EUR
11,300 for the first year and EUR 6,000 for subsequent years. This is inter
alia based on the assumption that already existing tasks in different
governmental departments relating to data collection activities on HEPA promotion
will be prioritised in order to comply with the new monitoring framework.
[1]               http://ec.europa.eu/governance/impact/planned_ia/roadmaps_2012_en.htm#EAC
[2]               Evidence on the benefits of physical activity and
costs of physical inactivity are outlined in Annex II.
[3]               In this regard a keynote speaker at the EU Sport
Directors meeting on 8/3/2013 noted: “Sport must be part of the solution.
Participation in sport is ‘fun’, connected with ‘play', and it is
'sustainable'. The latter was demonstrated by a recent study on sport’s
contribution to economic growth and employment in the EU showing the sector’s
exponential growth. Sport is sustainable – it ‘won’t go away’.”
[4]               See, inter alia: Effect of physical activity on major
non-communicable disease worldwide: an analysis of burden of disease and life
expectancy, The Lancet, Volume 380, Issue 9838,
Pages 219 - 229, 21 July 2012.
[5]               http://www.health.gov/paguidelines/Report/pdf/CommitteeReport.pdf.

[6]               Physical inactivity is the 4th leading risk factor
for global mortality. Increasing levels of physical inactivity are seen worldwide,
including in high-income countries. 
[7]               http://ec.europa.eu/health/nutrition_physical_activity/docs/implementation_report_a6_en.pdf.
[8]               This has been confirmed in discussions in several EU
level fora (EU Sport Directors; XG SHP; HLG; Platform). (See Annex I)
[9]               http://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf

[10]             An NCD is a medical condition or disease which by
definition is non-infectious and non-transmissible among people. NCDs include
autoimmune diseases, heart disease, stroke, many cancers, asthma, diabetes,
chronic kidney disease, osteoporosis, Alzheimer's disease, cataracts, and more.
(Wikipedia)
[11]             http://whqlibdoc.who.int/publications/2009/9789241597418_eng.pdf
[12]             WHO: Global Recommendations on Physical Activity for
Health. URL:
http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/index.html
[13]             http://www.un.org/ga/search/view_doc.asp?symbol=A/66/L.1
[14]             Report of the formal meeting of Member States to work
on the comprehensive global monitoring framework for the control and prevention
of NCDs, WHO, 21/11//2012. This global monitoring framework (GMF), including a
set of 25 indicators and 9 global voluntary targets, comes after nearly a year
of consultations led by WHO, and is one of the critical parts of the Global NCD
Framework.
[15]             The network carries out activities to encourage
cooperation and collaboration between government bodies, research institutions,
NGOs and other organisations in the field.
[16]             http://www.euro.who.int/__data/assets/pdf_file/0017/74402/E91153.pdf
[17]             http://www.euro.who.int/__data/assets/pdf_file/0019/170155/e96638.pdf
[18]             Cavill, Richardson, Foster, BHF Health Promotion
Research Group, Improving Health through Participation in Sport, a review of
research and practice. June 2012.
[19]             European Commission White Paper on Sport, COM(2007) 391
final. 
[20]             EU Physical Activity Guidelines - Recommended Policy
Actions in Support of Health-Enhancing Physical Activity, Brussels, 10 October
2008. URL:
http://ec.europa.eu/sport/library/documents/c1/eu-physical-activity-guidelines-2008_en.pdf
[21]             European Commission Communication “Developing the
European Dimension in Sport”, COM(2011) 12.
[22]             Council Resolution on a European Union Work Plan for
Sport 2011-2014, adopted on 11 May 2011, OJ C 162 of 1.6.2011.
[23]             The Council conclusions on promoting HEPA adopted in November
2012 give support to the EU PA GL and call on the COM to present a proposal for
a Council Recommendation on HEPA., doc. 15664/12 (LIMITE), 6 November 2012.
[24]             European Commission White Paper “A Strategy for Europe
on Nutrition, Overweight and Obesity-related health issues”, COM(2007) 279
final.
[25]             E.g. a recent call for proposals under the
‘Cooperation’ work programme within FP7 (FP7-HEALTH-2013-INNOVATION-1).
[26]             Already in 2009, transnational HEPA projects received
funding under the first Preparatory Action in the field of sport. In 2012, the
Preparatory Action European Partnership on Sports provides funding to
transnational projects in the field of physical activity supporting active
ageing:
http://ec.europa.eu/sport/preparatory_actions/introduction_en.htm 
[27]             European Commission: Special Eurobarometer 183-6 (December
2003), 213 The citizens of the European Union and Sport (November 2004), 246 Health
and Food (November 2006), 329 Health determinants (January 2010) and 334 Sport
and Physical Activity (March 2010).
[28]                    The 2010 Impact Assessment for the 2011 Communication on sport identified
the lack of physical activity as a main challenge in connecting with sport's
health-enhancing, social and educational function.
[29]             COM(2010) 2020 final.
[30]             Some MS, e.g. FI, have seen a positive development with
regard to their national physical activity levels.
[31]             Comprehensive evaluation data linking policies to the
evolution of physical activity rates in the EU are not available for all MS,
but looking at the countries for which data exist allows this link to be drawn.
In addition, the existence of the shortcomings in MS policy is further
demonstrated through examining more widely available data on policy development
and implementation and comparing it with international quality standards. These
two methods serve to identify the main shortcomings in this section (i.e.
aspects where national policies fall short of established good practice).
[32]             The importance of the EU PA GL as a reference framework
for shaping national strategies was regularly underlined by the policy level
(e.g. EU Sport Directors, HLG) and lately by the Council (draft conclusions on
HEPA; draft conclusions on healthy ageing across the lifecycle). Experts also
underlined that HEPA as a problem "is complex and it is highly
interdependent. Adequate policy instruments therefore have to be (…)
inter-sectoral. The EU PA GL reflect these needs". (See Annex I). Recent
years have seen several other efforts to develop such criteria, including the
publicly funded international inventories and comparative studies such as the
WHO Europe HEPA Policy Audit Tool (PAT).
http://www.euro.who.int/__data/assets/pdf_file/0006/151395/e95785.pdf
[33]             To do so, this IA draws on data from various studies
and research papers (many of them carried out under the auspices of WHO
Europe), consultation outcomes, large scale survey results and the outputs of
the WG on Sport and Health, the XG SHP and the HLG – also referred to in Annex
I.
[34]             Daugbjerg et al: Promotion of Physical Activity in the
European Region: Content Analysis of 27 National Policy Documents. Journal of
Physical Activity and Health, 2009, 6, 805-817.
[35]             Ibid.
[36]             Ibid.
[37]             The Lancet PA Series Working Group (see above).
[38]             For example, while FI has successfully
institutionalised the use of advisory committees for physical activity
including members from national ministries of health, education, culture,
environment, labour and transport, local authorities and NGOs, in NO the
mandate for a similar steering committee system was not renewed after it expired
in 2010. In NL the Ministry of Health, Welfare and Sport coordinates at a
policy level while implementation is coordinated by an NGO, the Netherlands
Institute for Sport and Physical Activity, whereas in CH responsibilities are
divided among national, cantonal and community-level actors. In PT and IT,
despite formal structures for collaboration and coordination, physical activity
is addressed separately by a number of ministries and other organisations,
leading to potential omissions and duplications.
[39]             XG SHP (meetings on 21/3 and 27/6/2012), EU Sport
Directors (meeting on 30/5-1/6/2012), HLG (meeting on 14/6 and written
submissions), work in the Council Working Party on Sport (Cypriot Presidency),
HEPA seminar with stakeholders (19/9, Nicosia). (See Annex I)
[40]             Review of physical activity promotion policy
development and legislation in EU MS, study jointly funded by the European
Commission and the WHO in 2010: http://www.euro.who.int/__data/assets/pdf_file/0015/146220/e95150.pdf.
[41]             The majority of countries did, however, include
education elements in sport policies. 
[42]             http://ec.europa.eu/sport/library/documents/b23/wg_sh_170311_meeting_report.pdf.

[43]             For example in plenary sessions of the EU Sport Forum,
organised by the European Commission.
[44]             The public online consultation, ’Strategic Choices for
the Implementation of the New EU Competence in the Field of Sport’, was
completed in 2010 by 1,326 stakeholders and other interested individuals. (See
Annex I)
[45]             NET-SPORT-HEALTH was one of 9 HEPA projects funded
under the 2009 Preparatory Action in the field of sport. http://www.euro.who.int/__data/assets/pdf_file/0006/147237/e95168.pdf.

[46]             Various types of document were included in the
selection, including legislation, policies, strategies and action plans as well
as other documents on health and physical activity. 
[47]             In order to facilitate the systematic collection of
comparable, timely data on physical activity, the WHO recommends administering
on a regular basis the questions from one of two available standardised
surveys: the International Physical Activity Questionnaire (IPAQ) or the Global
Physical Activity Questionnaire (GPAQ). Both questionnaires allow comprehensive
and comparable data to be recorded across a range of relevant factors of
physical activity, including the frequency, duration and level of intensity
both in general and in relation to specific activities. For more information,
see http://www.euro.who.int/__data/assets/pdf_file/0015/146220/e95150.pdf
[48]             A first overview on HEPA policy-related aspects is
available from the joint WHO/DG SANCO project on “Monitoring progress on
improving nutrition and physical activity and preventing obesity in the
European Union” (NOPA), which was carried out from 2008 to 2010. Additional
information on NOPA is provided in Annex III. http://www.euro.who.int/__data/assets/pdf_file/0015/146220/e95150.pdf.
[49]             Completed HEPA PATs for FI, IT, NL and PT: While FI
evaluates physical activity policy inter alia through the use of a yearly
postal survey, plans for evaluation in IT and PT are fragmented and incomplete.
The HEPA PAT for NL, which cites plans for evaluation in its National Action
Plan for Physical Activity, also notes that processes, results and effects of
policies are not evaluated in uniform and comparable ways.
[50]             EU Sport Directors meeting, 31/5-1/6/2012; HLG meeting on
14/6/2012; Expert Seminar on HEPA, 19/9/2012. (See Annex I)
[51]             Ibid.
[52]             The Lancet PA Series Working Group (see above). This
lack of advocacy and mobilisation is starting to change: an important player in
this regard can be the sporting goods industry, which is putting efforts in promoting
HEPA, e.g. via large ‘healthy lifestyle’ campaigns, such as, in 2012, “Designed
to move”.
[53]             "One problem is that physical activity is often
perceived only in the context of controlling obesity, and therefore physical
inactivity is regarded as a minor or secondary risk factor for NCDs" P.
Das, R. Horton, Rethinking our approach to physical activity (The Lancet, Vol
380, Issue 9838, p. 189-190; 12 July 2012).
[54]             While the global NCD approach is considered important,
according to WHO experts, regarding physical activity that approach is too
limited; it does for instance not include ‘urban design’.
[55]             Physical Activity Guidelines Advisory Committee,
Report, 2008, Washington, DC: US Department of Health and Human Services, 2008.
[56]             The Lancet PA Series Working Group (see above). 
[57]             Ibid: “For physical activity
the science of how to change individual behaviours has overshadowed efforts to
understand true population change. Because of this unbalanced focus, the
structural and systemic changes necessary to promote physical activity in populations
(…) across various sectors have not yet been addressed systematically. (…) A
similar experience occurred in tobacco control, where initially the burden of
responsibility was put solely on individuals. Once that view expanded to
include recognition of societal responsibility as well, population-level action
and changes in smoking prevalence followed.” 
[58]             This is not only reflected by expert opinion, but also
by EU-funded projects like PASEO that analysed the policy capacity for PA
promotion among older people in 15 EU MS, or MOVE that looked into the
capacities of sport for all organisations to reach socially disadvantaged groups
through HEPA. 
[59]             This is also shown by the
review of 27 national policy documents for physical activity promotion, which
suggested that, with a few notable exceptions, the development of national
policy documents on physical activity in Europe has only started in recent
years. See Daugbjerg et al: Promotion of Physical Activity in the European
Region: Content Analysis of 27 National Policy Documents. Journal of Physical
Activity and Health, 2009, 6, 805-817.
[60]             E.g. for the 2006 Istanbul
conference on obesity or for the 2009 NET-SPORT-HEALTH project focal points
[61]             For instance, in the margins of the EU Sport Directors
meeting on 8 March 2013 certain MS representatives confirmed the impact of the
crisis on activities relating to HEPA promotion, e.g. the French Ministry in
charge of sport does not support anymore the promotion campaign “Santé vous
sport”. Or statement at a conference on the financing of sport on 16/2/2010 in
Brussels, according to which “Public budget austerity is under way in the EU-27
and sport budgets cannot escape budgetary stagnation or cuts”.
[62]             This disparity is confirmed in the final Evaluation of
that strategy (p. 162): .http://ec.europa.eu/health/nutrition_physical_activity/docs/pheiac_nutrition_strategy_evaluation_en.pdf 
[63]             E.g. Physical activity has stayed outside the European Innovation
Partnership on Active Ageing or the Social Investment Package (Commission Communication
(COM(2013) 83final) and related Staff Working Documents ("Long-term
care" and "Investing in health"). The latter develops on health
as an investment in human capital and highlights the importance of devoting
resources to health promotion and disease prevention which should make use of
different settings. Physical activity is not being considered.
[64]             According to a recent review of the implementation of
the GL carried out by the XG SHP in 2012, 16 MS were able to provide
information demonstrating how national guidelines and/or policies reflected the
provisions of (at least some of) the GL. Source: Information in the
"Implementation table" (see Annex I)
[65]             The view that ‘the EU should do better in promoting the
public health dimension of sport‘ was also the main conclusion in a keynote
address at the EU Sport Directors meeting, on 8/3/2013 in Dublin. 
[66]             Unlike the WHO which is mandated to support governments
and health authorities through a regional director who has primary allegiance
to Ministries of Health, the EU offers much broader scope for cooperation among
the governments of the MS, which is particularly important to promote a multi-sectoral
approach to HEPA.
[67]             As expressed, for instance, by EU Sport Directors (see
Annex I) and in the 2011 Evaluation of the Preparatory Actions in the field of
sport, which found that ‘while data on the ultimate impacts of the activities
carried out so far is lacking, tackling these transnational issues [incl.
physical inactivity] at European level provides policy makers with the
information needed to develop effective and coherent policies. Bringing
stakeholders from around Europe together also reinforces the European dimension
of the issues at hand.’
[68]             As confirmed by several MS in the political debates at
EU level (see Annex I).
[69]             Ibid.
[70]             Details can be found in Annex I.
[71]             For example, the major achievement of the HLG since its
inception in 2007 is the Common Framework for salt reduction, while new initiatives
are currently being explored in the areas of sugar and fat reduction. Minutes
from the 15 HLG meetings held until mid-2012 demonstrate that nutrition issues
play a far larger role in the discussions than physical activity. According to
the Evaluation of the Strategy "nearly all HLG members agreed that physical
activity played only a small role in the discussions" (p. 33) – see fn 62.
[72]             The Evaluation of the Strategy concluded that "Physical activity was perceived as playing only a small role in HLG
discussions despite its importance for reducing overweight and obesity; a
considerable proportion of HLG members saw this as a pragmatic choice that
reflected the expertise and competences of participants, many of whom do not
have responsibility for physical activity promotion" (p. 36) – see fn 62.
[73]             E.g. Global Strategy on Diet, Physical Activity and
Health (WHO, 2004); Action Plan for the Global strategy for prevention and
control of NCDs 2008-2013 (WHO), Political declaration of the High-level
Meeting of the General Assembly on the Prevention and Control of NCDs (UN,
2011), Parma Declaration on Environment and Health (WHO Europe, 2010), Action
Plan for implementation of the European Strategy for the Prevention and Control
of NCDs 2012-2016 (WHO Europe).
[74]             It is telling that the majority of MS representatives
and experts consulted for this initiative have identified as a key problem the
lack of a cross-sectoral approach and called for additional action. This in
turn confirms that the status quo does not work in a satisfactory way (see also
Annex I). 
[75]             E.g. by the XG SHP, EU Sport Directors, the HLG,
experts (see also Annex I).
[76]             See Annex I.
[77]             This is also reflected in the recent Council conclusions
on closing health gaps that invited the MS to "promote policies and
actions that sustain the health of working age people leading to a healthy
workforce, as a prerequisite for productivity and growth". (See Annex I)
[78]             European Commission White Paper “Together for Health: A
Strategic Approach for the EU 2008-2013”, COM(2007) 630 final.
[79]             European Commission White Paper “A Strategy for Europe
on Nutrition, Overweight and Obesity related health issues”, COM(2007) 279
final.
[80]             Council Conclusions on closing health gaps within the
EU through concerted action to promote healthy lifestyle behaviours, 1-2
December 2011.
[81]             European Commission Communication “Action Plan on Urban
Mobility”, COM(2009) 490 final.
[82]             European Commission Communication “European Disability
Strategy 2010-2020: A Renewed Commitment to a Barrier-Free Europe”, COM(2010)
636 final.
[83]             FP7 Cooperation Work Programme Health 2013 (Social
innovation for health promotion): http://ec.europa.eu/research/participants/portal/page/cooperation?callIdentifier=FP7-HEALTH-2013-INNOVATION-1
as well as FP7 research projects from the diabetes/obesity area, such as
DEXLIFE (http://www.delife.eu) and
METAPREDICT (http://metapredict.eu). The FP
7 ENERGY project inter alia noted that parents' physical activity is an
important predictor of physical activity in children. It is however not
considered politically feasible to address parenting behaviour within the
context of the present initiative, which is, moreover, based on the EU PA GL
that do not have a specific focus on parents.
[84]             Impact assessment on the Proposal for a Regulation
establishing "ERASMUS FOR ALL", The Union Programme for Education,
Training, Youth and Sport. SEC(2011) 1402
[85]             A recent evaluation of
Preparatory Actions in the field of sport also confirms the role of projects to
support policy development and to inform and shape policy-making, however not
to replace it. Final report: Framework contract EAC/50/2009.
[86]             These focal points have a coordinating role and could possibly
function as a subgroup within the currently existing WHO-led national focal
points which so far have mostly focused on nutrition aspects. EU monitoring arrangements
currently supported within a two-year WHO/COM project might continue in some
form also after mid-2014; they would take into account the new PA monitoring
framework and new reporting structures.
[87]             For instance, regular surveys would be carried out
using standardised questionnaires and reporting tools. Such information would
be verified and abstracted into the WHO NOPA database. A system would be
established to allow ad-hoc snapshots of country implementation levels, using
the EU PA GL monitoring framework. Such reports would be delivered to the
Commission at regular intervals.
[88]             Pilot testing of such support is provided under the
2013 Preparatory Action in the field of sport, based on a direct agreement
between the COM (EAC) and WHO Europe, involving the HEPA Europe expert network.
[89]             In their recent discussions in the Working Party on
Sport, a number of MS representatives have been supportive to the idea a
Council Recommendation. (See Annex I)
[90]             Given the wide range of actors involved in implementing
the new initiative, and the fact that it will be implemented at MS rather than
EU level, quantitative predictions concerning the precise benefits and costs
are difficult and necessarily based on extrapolations from a limited supply of
reliable data.
[91]             Physical activity and health in Europe, WHO Europe, http://www.euro.who.int/__data/assets/pdf_file/0011/87545/E89490.pdf.

[92]             Ibid.
[93]             According to the 2010 Eurobarometer on sport, the
countries with the highest inactivity rates are all in Southern and Eastern
Europe. Moreover, lack of leisure-time physical activity tends to be more
common in the lower socio-economic groups – these people tend to die at a
younger age and to have, within their shorter lives, a higher prevalence of all
kinds of health problems. http://ec.europa.eu/public_opinion/archives/ebs/ebs_334_en.pdf.
[94]             There are large differences between MS, due to a number
of factors that determine health, including variations in living and working
conditions, as well as in lifestyles. See COM(2013) 83 final.
[95]             S. C. Moore et al, Leisure time physical activity of
moderate to vigorous intensity and mortality: a large pooled cohort analysis.
PLoS Medicine, 2012; 9 (11).
[96]             Calculated on the basis of Eurostat physical activity (http://ec.europa.eu/sport/library/documents/d/ebs_334_en.pdf)
and life expectancy data (http://epp.eurostat.ec.europa.eu/statistics_explained/images/2/20/Mortality_and_life_expectancy_statistics_YB2013.xls).

[97]             http://www.thl.fi/thl-client/pdfs/4582dc7b-0e9c-43db-b5eb-68589239b9a3

[98]             WHO discussion paper, 22 March 2012, http://www.searo.who.int/LinkFiles/mhnd_GMF.pdf.

[99]             Formal meeting of Member States to conclude the work on
the comprehensive global monitoring framework, including indicators, and a set
of voluntary global targets for the prevention and control of NCDs, WHO, Geneva,
5–7 November 2012. On 27 May 2013, the World Health Assembly in Geneva has
adopted an "Omnibus
Resolution", endorsing the WHO Global Action Plan 2013-2020 for the
prevention and control of non-communicable diseases NCD and adopting the
respective global monitoring framework and the set of nine voluntary global
targets, including one on physical inactivity.
[100]            Game Plan: a strategy for delivering Government’s sport
and physical activity objectives, http://www.cabinetoffice.gov.uk/media/cabinetoffice/strategy/assets/game_plan_report.pdf.
This figure can be seen as a realistic calculation since in other countries
studies identified similar or higher costs (Annex II).
[101]            The variables of the UK estimate, which are based on the
costs to the NHS of lost day income and costs of premature death also based on
lost income, are hence likely to differ across the EU. Nonetheless, this
calculation serves as an approximation and uses the few data available. 
[102]            Figures are based on the methodology used for the
British government report Game Plan and Eurostat population figures. 
[103]            At a recent meeting of the XG SHP FI confirmed that
exact numbers on the effects of multisectoral co-operation on PA levels and the
exact costs involved could not be provided at present. FI however also stated
that "multisectoral co-operation has been experienced as being extremely
valuable and crucial" and that "as a result of the governmentally
directed nationwide cross-sectoral programmes to promote HEPA, after ten years
of working, physical activity is stated as one of the main tools to improve
health and wellbeing in the strategies of main cities".
[104]            This is why a new indicator on "Funding allocated
specifically to HEPA promotion" is proposed to be included in the new
monitoring framework accompanying the Commission's proposal.
[105]            It should also be noted that a range of factors other
than policies specifically aimed at increasing HEPA can lead to increases in
physical activity levels, such as noted for FI.
[106]            The hourly rate is the EU hourly wage average of ISCO 2
Professionals, taken from the Administrative Burden Calculator.
[107]            The estimates are informed by the amount of time needed
to collect and manage data for the NOPA database and HEPA PAT, and the fact
that Option D would comprise significantly more indicators than Option C,
requiring feedback from more stakeholders and more analysis.
[108]            Indicative annual allocation of the budget for HEPA
estimated in the 2011 IA for the Sport Chapter: €8m.
[109]            A precise breakdown of costs will be possible after the
implementation of the 2013 Preparatory Action (direct agreement with WHO Europe
to test the monitoring framework).
[110]            Woodcock, J. et al, Public health benefits of strategies
to reduce greenhouse-gas emissions: urban land transport, The Lancet, Volume
374, Issue 9705, pages 1930-1943, 5 December 2009.
[111]            In this section, the scale in the tables compares the
option against the baseline scenario. Thus, each '0' indicates the same rating
as the continuation of the status quo, 'pluses' indicate that options rate more
favourable than the status quo (i.e. because they are more likely to be
effective).
[112]            As expressed by MS, e.g. at EU Sport Directors meetings
or XG SHP meetings. (see Annex I)
[113]            The IA for the Sport Chapter of the Erasmus+ programme
also found that without further action progress to address the physical
inactivity challenge would continue to be highly uneven.
[114]            The Evaluation of the Strategy on Nutrition, Obesity and
Overweight-related Health issues found that the HLG made a significant
contribution to progress on salt reduction, whereas discussions on other topics
had few tangible results. The report also noted that "existing instruments
have addressed nutrition to a considerably greater extent than physical
activity. In order to alleviate this disparity, the Commission could focus on
raising the profile of nascent initiatives which do focus on physical activity,
such as the Expert Group on Sport, Health and Participation, (…)." (p.
162) – see fn 62. 
[115]            For this reason, the WHO represented in a recent HLG
meeting in Brussels stated that in order to keep the database alive the
cooperation of and input from the MS was required (see Annex I). 
[116]            See remark from Czech HLG member in his written
submission (see Annex I).
[117]            This has been confirmed by several MS in the
consultation process (see Annex I).
[118]            MS noted inter alia that a renewed focus on the EU PA GL
would "encourage engagement of national authorities". (Annex I).
[119]            MS welcomed the "complexity and simple
implementation" of this option. (Annex I)
[120]            EU Sport Directors (6/2012) and HLG (6/2012). (Annex I).
[121]            Statements in these fora can be found in Annex I.
[122]            MS noted that the monitoring framework would enable them
to evaluate the impact of their national policies. (see Annex I).
[123]            This was noted in a HLG meeting. (see Annex I)
[124]            Several MS have indeed expressed concerns with regard to
'too extensive reporting requirements', the 'non-availability of data' and the
'need to plan the financial mechanism for data collection carefully'. (see
Annex I)
[125]            This has been confirmed in the discussion with MS
representatives (XG SHP, Sport Directors, HLG). (see Annex I).
[126]            This can be expected to be the case especially for those
MS facing financial austerity measures and a lack of enthusiasm for the EU. SE
for instance has argued against a Council Recommendation and EU monitoring, in
the Council; and several MS have expressed concern with regard to
funding/adequate budgets (see Annex I).
[127]            As explained in chapter 5.2, these costs are very
difficult to quantify for the MS due to the lack of information available on
the funding of current HEPA interventions. It is therefore proposed to include
in the new monitoring framework one indicator on funding allocated to HEPA
promotion.
[128]            http://www.liv.ac.uk/PublicHealth/obs/publications/report/83_28th
_Feb_Physical_activity_and_cost_FINAL.pdf
[129]            Cost effectiveness of community-based physical activity
interventions, American Journal of Preventive Medicine, Volume 35, Number 6,
2008.
[130]            Proper, K., Effectiveness and economic impact of
worksite interventions to promote physical activity and healthy diet, WHO,
2007. 
[131]            Legend for the values used: 0 not cost effective, +
partly cost effective, ++ cost effective.
[132]            COM(2011) 12 final.
[133]            http://www.bso.or.at/fileadmin/Inhalte/Dokumente/Internationales/EU_Study_Young
_Lifestyle.pdf.
[134]            Reports from meetings:
http://ec.europa.eu/sport/library/consultation-and-co-operation_en.htm#health
[135]            COM(2007) 391 final.
[136]            Full text of the EU PA GL:
http://ec.europa.eu/sport/library/documents/c1/eu-physical-activity-guidelines-2008_en.pdf
[137]            COM(2007) 279 final.
[138]            EU PA GL implementation table:
http://ec.europa.eu/sport/library/documents/c1/pag-implementation-table-revised-20120629.pdf
[139]            Regarding the reporting on PA, there are however no
details provided in this report. Moreover, it is stated that the 'report
benefitted from valuable contributions from the WHO Europe network of National
Food Information Focal Points, from the Members of the HLG as well as from COM
services, in particular DG RTD and AGRI'. In which way PA relevant actors or
experts have been involved is not immediately visible. Strategy for Europe on
nutrition, overweight and obesity-related health issues; Implementation
progress report, December 2010.
[140]            The evaluation report furthermore states (p. 45): "The second indicator in particular refers clearly to two types of
initiative: physical activity guidelines, and education campaigns to
raise awareness. One could imagine two NCPs reporting an identical situation in
more than one way. Moreover, the two indicators are very narrow in scope. A
true assessment of MS action on physical activity initiatives would need to
consider myriad interventions aimed at many target groups and taking place in
many settings. In addition, the EU Physical Activity Guidelines, published in
November 2008, emphasise the need for a cross-sectoral approach to
physical activity promotion, which the two indicators above do not capture.
Leading from this, there are no comprehensive studies that examine progress
against the two indicators subsequent to 2010. (…) While it is clear that many
individual initiatives exist in the MS to promote physical activity, some of
which are making positive impacts, it is also clear that in most countries a
sufficiently holistic and comprehensive approach is not being followed." http://ec.europa.eu/health/nutrition_physical_activity/docs/pheiac_nutrition_strategy_evaluation_en.pdf
[141]            Council Resolution on an EU Work Plan for Sport, 11 May
2011, OJ C162 of 1.6.2011.
[142]            First set of deliverables submitted to the Council
Working Party on Sport:
http://ec.europa.eu/sport/library/consultation-and-co-operation_en.htm#xgshp
[143]            Full report from the XG SHP to the Council:
http://ec.europa.eu/sport/library/consultation-and-co-operation_en.htm#xgshp
[144]            Internal report: SI (2011) 45
[145]            Internal report: SI (2011) 378
[146]                  Internal report: SI
(2012) 416
[147]            NB: The two latter statements are factually incorrect.
[148]            Council of the European Union, Council conclusions on
"Closing health gaps within the EU through concerted action to promote
healthy lifestyle behaviours", doc. 16708/11, 17 November 2012; text
adopted on 1-2 December 2011.
[149]            Council of the European Union, Draft Council conclusions
on "Healthy Ageing across the Lifecycle", doc. 15098/12, 19 October
2012.
[150]            2011/2087(INI) of 2 February
2012.
[151]            Information given and statements made in this section
are further laid down in internal mission reports (COM participation in HEPA
Europe Annual Meetings and Conferences 2008-2012).
[152]            COM presence at the following meetings: 1st Annual
Conference of HEPA Europe and 4th Annual Meeting of HEPA Europe (8-10 Sept.
2008, Glasgow, UK); 5th Annual Meeting + Symposium (11-12 Nov. 2009,
Bologna, IT); 6th Annual Meeting + Symposium (24-26 Nov. 2010,
Olomouc, CZ); 7th Annual Meeting (11-13 Oct. 2011, Amsterdam, NL); 8th
Annual Meeting (25-27 Sept. 2012, Cardiff, UK).
[153]                  Internal report: SI
(2012) 416
[154]         http://ec.europa.eu/health/archive/ph_determinants/life_style/nutrition/platform/docs/
platform_charter.pdf
[155]            Other organisations, such as the European
Heart Network, European Region of the World Confederation for Physical Therapy,
the European Association for the Study of Obesity, European Public Health
Alliance, EuroHealthNet, European Network for prevention and Health Promotion
in general practice/family medicine, The International Diabetes Federation –
European Region, and the International Obesity Task Force also showed interest
in physical activity promotion.
[156]            http://ec.europa.eu/health/nutrition_physical_activity/docs/evaluation_frep_en.pdf
[157]         The
term "organisation" has been used in a wide sense, including sport
organisations (e.g. a sport federation), sport-related organisations (e.g. a
sports betting provider), public authorities (e.g. a Ministry) or public bodies
(e.g. a sport agency), as well as private companies, research centres or
universities, consultancies, and some others.
[158]            Full report:
http://ec.europa.eu/sport/documents/library/100726_online_consultation_report.pdf
[159]            http://www.who.int/healthinfo/global_burden_disease/global_health_risks/en/index.html
[160]                  ibid.
[161]                  OECD (2010), Health at a Glance: Europe 2010, OECD Publishing.
[162]                  http://www.who.int/chp/ncd_global_status_report/en/index.html

[163]                  E.g. Journal of Public Mental Health, Official journal of the
association of medicine and psychiatry, International Journal of Mental Health
Promotion, Journal of Physical Education & Sport
Pedagogy
[164]                  Sports Medicine,
Volume 29, Number 3, 1 March 2000 , pp. 167-180(14).
[165]                  Current Opinion in Psychiatry: March 2005 - Volume 18 - Issue 2 - p
189-193.
[166]                  E.g. A. Fedewaa, S. Ahn, The Effects of
Physical Activity and Physical Fitness on Children's Achievement and Cognitive
Outcomes, Research Quarterly for Exercise and Sport, Volume 82 – Issues 3,
2011.
[167]                  Rimmele et al, Level of PA affects adrenal and Cardiovascular
Reactivity to Psychosocial Stress: Psychoneuroendocrinology (2009) 43 190-198;
Puterman E, Lin J, Blackburn E, O'Donovan A, Adler N, et al. (2010), The Power
of Exercise: Buffering the Effect of Chronic Stress on Telomere Length.
[168]            K. Abu-Omar, A. Rütten, V. Lehtinen,
International Journal of Public Health, Volume 49, Issue 5, pp 301-309, August 2004. 
[169]            The Lancet, Volume 380, Issue 9838, pages 192-193, 21
July 2012.
[170]            ibid.
[171]            http://www.euro.who.int/en/what-we-do/health-topics/diseases-and-conditions/obesity 
[172]            WHO Europe (2007): A European
framework to promote physical activity for health, p. 9. URL:
http://www.euro.who.int/__data/assets/pdf_file/0020/101684/E90191.pdf
[173]            K I Proper,
S G van den Heuvel, E M De Vroome, V H Hildebrandt and A J Van der Beek:
Dose–response relation between physical activity and sick leave. Br. J. Sports
Med. 2006;40;173-178
[174]            Risikofaktorer og folkesundhed i
Danmark. [Risk factors and public health in Denmark]. Copenhagen, Statens
Institut for Folkesundhed, 2006. English summary available at:
http://www.si-folkesundhed.dk/upload/2745_-_risk_factors_and_public_health_in_denmark.pdf
[175]            The higher and lower estimates correspond to alternative
approaches to estimating the production loss, namely the human capital method and
the friction method. GDP data is based on Eurostat.
[176]            http://unipub.lib.uni-corvinus.hu/440/1/Kszemle_CIKK_1259.pdf
[177]            http://www.medibank.com.au/Client/Documents/Pdfs/pyhsical_inactivity.pdf
[178]            http://sgsm-ssms.ch/ssms_publication/file/79/7-2001-3.pdf
[179]            Study carried out by the Norwegian Institute of
Transport Economics in 2002 (cost-benefit analysis taking into account the
health consequences of cycling and walking), http://www.cycle-helmets.com/denmark.pdf. 
[180]            http://www.bso.or.at/fileadmin/Inhalte/Dokumente/Turnstunde/Praesentation_Studie
_Turnstunde.pdf
[181]            For Ireland, the
economic cost of physical inactivity have recently stated to be “over €300
million per annum”. IE Presidency Conference, 8/3/2013.
[182]            European Commission: Special Eurobarometer 183-6
(December 2003). URL: http://ec.europa.eu/public_opinion/archives/ebs/ebs_183_6_en.pdf.

[183]            European Commission: Special Eurobarometer 246 (November
2006). URL: http://ec.europa.eu/health/ph_publication/eb_food_en.pdf.

[184]            Special Eurobarometer 213 (November 2004) and 334 (March
2010). To be noted: While some of the increase between 2004 and 2010 can be
attributed to the inclusion of Bulgaria and Romania to the latter survey, it is
clear that sport / exercise rates fell overall. 
[185]            In response to these findings, the PT government has
been looking for new policy strategies and programmes
that could overcome these results and improve sport and physical activity
participation, contributing to enhance health and well-being across generations
(XG SHP meeting, July 2013).
[186]            Special
Eurobarometer 329 on health determinants: http://ec.europa.eu/public_opinion/archives/ebs/ebs_329_sum_en.pdf).
[187]            http://ec.europa.eu/public_opinion/archives/ebs/ebs_378_en.pdf
[188]            Strong et al., 2005; Borraccino et al., 2009; Hallal et
al., 2012.
[189]            Health at the Glance 2012 (OECD): http://www.oecd-ilibrary.org/sites/9789264183896-
en/02/04/index.html;jsessionid=97t37ei8gnkj.x-oecd-live-02?contentType=&itemId=/content/chapter/9789264183896-23-en&containerItemId=/content/serial/23056088&accessItemIds=/content/book/9789264183896-en&mimeType=text/html
[190]            http://www.euro.who.int/__data/assets/pdf_file/0005/148784/e95584.pdf.

[191]            THL — Report 25/2011: Social Determinants of Health
Behaviours Finbalt Health Monitor 1998–2008, p 82. URL: http://www.thl.fi/thl-client/pdfs/f316c417-cc1d-48e6-a2e2-7389fde28630.

[192]            Department of Health: Health Survey for England. URL: www.dh.gov.uk/en/publicationsandstatistics/publishedsurvey/healthsurveyforengland/healthsurveyresults/index.htm
[193]            Department of Health and Children:
Survey of Lifestyle, Attitudes and Nutrition in Ireland, 2008. Regarding sport,
the Chief Executive of the Irish Sports Council noted at the IE Presidency
Conference on 7/3/2013 “the proportion that is ‘highly active’ adults increased
from 26% to 30% between 2009 and 2011. (…) We acknowledge that there is a major
challenge in keeping the rates at high level and that it is a sustained
increase in engagement in sport and not a short term phenomena.”
[194]            Les principales activités physiques et sportives pratiquées
en France en 2010: 
                http://www.sports.gouv.fr/IMG/pdf/Stat_Info_no11-02_de_novembre_2011.pdf
[195]            Ministry of Health: Behaviour Risk Factor surveillance
system (PASSI). Annual reports 2007, 2008 and 2009. URL:
http://www.epicentro.iss.it/passi/sorvRisultatiNazionale.asp
[196]            The English data refers to those who report 30 minutes
or more of moderate or vigorous activity on at least five days per week.
The IE data refers to the percentage reporting moderate and/or strenuous
exercise three or more times per week for at least 20 minutes. The IT data
includes those who either carry out "hard labour" (lavoro pesante)
or meet government PA guidelines (30 minutes of moderate PA on five or
more days per week, or more than 20 minutes of vigorous PA on at least
three days per week).
[197]            For instance a recent BBC report (14/12/2012) ‘Why are Swedish women healthier than the British?’ illustrated how
successful SE has been in engaging females in sport and physical activity.
[198]            http://ec.europa.eu/sport/library/documents/c1/eu-physical-activity-guidelines-2008_en.pdf
[199]            E.g. http://www.euro.who.int/en/what-we-publish/abstracts/young-and-physically-active-a-blueprint-for-making-physical-activity-appealing-to-youth
[200]            E.g. http://www.eunaapa.org/Products/Best_Practice_Reports/
[201]            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.
[202]            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) 
[203]            General approach to develop a
monitoring framework presented but not the detailed list of indicators. 
[204]            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.
[205]            http://www.who.int/dietphysicalactivity/factsheet_adults/en/index.html
[206]            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%. 
[207]            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. 
[208]            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.
[209]            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. 
[210]            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 from 16
countries had a sport focus and 22 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).
[211]            WHO Regional Office for Europe (2010): Review of
physical activity surveillance data sources in European Union Member States.
WHO/Commission 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). 
[212]            http://www.euro.who.int/hepapat

[213]            Identification number of the contribution agreement:
2011 52 02. Contracting authority: EAHC.