Description of monitoring and surveillance systems currently measuring key policy indicators.
Indicators were matched to variables in 17 different monitoring and surveillance systems and databases (Table 1). Eleven of these are managed by an EU body, such as Eurostat or the European Commission, four are managed by the WHO and five are managed by non-governmental organisations, academic institutes or foundations.
Monitoring system/database
|
Organisation
|
Childhood Obesity Surveillance Initiative (COSI)
|
WHO Regional Office for Europe
|
EPHA policy mapping
|
European Public Health Alliance
|
European Injury Data Base
|
The European Commission
|
EEA-Indicators: European Air Quality Index
|
European Environment Agency
|
EFSA Food composition database
|
European Food Safety Authority
|
European Health Interview Survey (EHIS)
|
Eurostat
|
Eurobarometer 88.4
|
The European Commission
|
European social survey (ESS)
|
European Research Infrastructure Consortium (ERIC)
|
European Union Statistics on Income and Living Conditions (EU-SILC)
|
Eurostat
|
Eurostat Food Price Monitoring Tool
|
Eurostat
|
Global dietary database
|
Tufts Friedman School of Nutrition Science and Policy
|
Health Behaviour in School-aged Children Survey (HSBC)
|
WHO Regional Office for Europe
|
HEPA PAT
|
WHO Regional Office for Europe
|
OpenStreetMap
|
OpenStreetMap Foundation (OSMF)
|
Special Eurobarometer 472: Sport and physical activity
|
The European Commission
|
Survey of Health, Ageing and Retirement in Europe (SHARE)
|
European Research Infrastructure Consortium (ERIC)
|
WHO Global Nutrition Policy Review
|
World Health Organisation
|
Table 1. Monitoring and surveillance systems and databases that provided variable matches for the key policy indicators
Summary of key indicators mapped to existing monitoring and surveillance systems
Measures within existing EU monitoring systems were found for 72% of diet indicators and 86% of physical activity and sedentary behaviour indicators (Table 2). Indicators at the individual level (individual determinants and behaviour outcomes) were well covered by existing monitoring systems. For the diet indicators, 80% of individual determinant indicators and 73% of behaviour outcome indicators were matched with a suggested variable. Potential variables were suggested for 85% of PA/SB behaviour outcome indicators. At policy level, 84% of PA/SB indicators and 70% of diet
indicators were mapped to existing measures.
Table 2. Summary of indicators that were matched to variables in existing monitoring and surveillance systems
|
Diet indicators
|
Physical activity and sedentary behaviour indicators
|
Level
|
Matched
|
Not matched
|
Matched
|
Not matched
|
|
n(%)
|
n(%)
|
n(%)
|
n(%)
|
|
|
|
|
|
Policy
|
26 (70)
|
11 (30)
|
27 (84)
|
5 (16)
|
Determinants (Environmental)
|
7 (64)
|
4 (36)
|
14 (100)
|
0 (0)
|
Determinants (Interpersonal)
|
2( 67)
|
1 (33)
|
6 (75)
|
2 (25)
|
Determinants (Individual)
|
8 (80)
|
2 (20)
|
0 (0)
|
0 (0)
|
Behaviour outcomes
|
9 (82)
|
2 (18)
|
11 (85)
|
2 (15)
|
Total
|
52 (72)
|
20 (28)
|
57 (86)
|
9 (14)
|
|
|
Assessing the suitability of suggested variables as indicator measures using a Likert scale
Measures that were matched to indicators in the initial mapping stage were assessed for suitability using a Likert scale (not matched, less matched, somewhat matched, matched). Examples of matched indicator-measure pairs at each Likert scale point are given in Table 3.
58% of diet indicator-measure pairs and 80% of PA/SB indicator-measure pairs were classified as ‘matched’ on the Likert scale (i.e. the variable was very suitable for measuring the indicator). The ‘less matched’ scale point had the least indicator-measure pairs for both diet and PA/SB, 11% and 7% respectively.
Table 3. Examples of PEN key indicators matched at each level of the Likert scale.
Diet indicators
|
Likert scale point
|
Key indicator
|
Matched variable in EU monitoring/surveillance system
|
Matched
|
Fruit intake, portions per day
|
EHIS
Number of portions of fruit a day, excluding juice
|
Somewhat matched
|
Sugar-sweetened beverages, glasses per day
|
COSI, Family Survey
Over a typical or usual week, how often does your child eat or drink the following kinds of food/beverages? Soft drinks containing sugar
· Never
· <1per week, some days (1-3),
· Most days (4-6),
· Every day
|
Less matched
|
Food and nutrition insecurity
|
EU SILC,
Capacity to afford a meal with meat, chicken, fish (or vegetarian equivalent) every second day
|
Physical activity and sedentary behaviour indicators
|
Matched
|
Availability of indoor activity space in school
|
COSI School record form (mandatory)
Does your school have an indoor gym?
· Yes
· No
|
Somewhat matched
|
Time spent with aerobic physical activity in a typical week.
|
EHIS
During the past 7 days, on how many days did you do moderate physical activities? Days per week
|
Less matched
|
Condition of active commuting infrastructure to and from kindergarten/school/university/ work
|
COSI Family Survey (voluntary)
If your child doesn’t walk or ride a bicycle, skateboard or non-motorized scooter from home to school or vice versa, please indicate the reason(s):
· the route is not safe
· the school is too far from home
· the child does enough physical activity during the day
· lack of time
· other (Specify:________)____________
|
Abbreviations : EHIS, European Health Interview Survey; COSI, Childhood Obesity Surveillance Initiative; EU SILC, European Union Statistics on Income and Living Conditions; HBSC, Health Behaviour in School-aged Children Survey (HSBC).
|
Indicators that were not matched
At the end of the mapping process, 28% of diet indicators and 14% of PA/SB indicators were not matched with variables in existing monitoring and surveillance systems.
Indicators at policy level made up 55% of unmatched diet indicators. These indicators came under the policy domains of ‘Funding and Resources’, ‘Inequality’, ‘Governance’, ‘Monitoring and Evaluation’ and ‘Retail’ (Table 4). The remaining 45% of unmatched indicators were spread equally across determinants (environmental, interpersonal and individual) and behaviour outcomes. These indicators covered a wide range of domains including environmental food availability and accessibility, portion size, household food literacy level, food beliefs, minority group specific indicators and situational and time constraints.
PA/SB indicators that were not matched were spread evenly across the indicator levels (Table 4). At policy level, unmatched indicators were related to ‘Active Environments’ including government support for urban design, public transport and road safety and financial incentives for PA promotion under the Active Societies domain. These indicators were adapted from the MOVING framework (14) and WHO GAPPA(15). At the determinants and behaviour outcome levels, unmatched indicators covered the availability and accessibility of activity spaces, specifically in the kindergarten, university and workplace setting. School setting indicators were matched with variables in the WHO COSI (19) and in Health Behaviour in School-aged Children Survey (HSBC)(23). Other indicators that were unmatched included those relating to supportive behaviour by friends and parents, non-organised sports participation and PA in the kindergarten setting.
Table 4. PEN key diet indicators that are not currently available in EU monitoring systems
Indicator dimension
|
Indicator domain
|
Indicator
|
Policy Indicators
|
Policy
|
Funding and Resources
|
FUND2: Government funded research is targeted for improving food environments, reducing obesity, NCDs and their related inequalities.
|
Policy
|
Funding and Resources
|
FUND3: There is a statutory health promotion agency in place that includes an objective to improve population nutrition, allocated with a specific budget line.
|
Policy
|
Governance
|
GOVER2: Policies and procedures are implemented for using evidence and Health Impact Assessments in the development of food and nutrition policies.
|
Policy
|
Governance
|
GOVER3: Policies and procedures are implemented for ensuring transparency in the development of food and nutrition policies, including transparent guidelines on how to involve industry and mechanisms to safeguard against conflicts of interest and protect public’s interest.
|
Policy
|
Inequality
|
INEQUAL1: Systems are in place to regularly monitor household food and nutrition insecurity at a National level.
|
Policy
|
Inequality
|
INEQUAL3A: There are processes in place to ensure that population nutrition, health outcomes and reducing health inequalities or health impacts in vulnerable populations are considered and prioritised in the development of all government policies relating to food.
|
Policy
|
Inequality
|
INEQUAL5: Waste reduction policies for food retail and food service outlets are in place.
|
Policy
|
Monitoring and evaluation
|
MONIT6: Progress towards reducing health inequalities or health impacts in vulnerable populations and social and economic determinants of health are regularly monitored.
|
Policy
|
Retail
|
RETAIL1 : Zoning laws and policies are implemented to place limits on the density or placement of quick serve restaurants or other outlets selling mainly unhealthy foods in communities, particularly around schools, and/or access to these outlets, (such as opening hours.
|
Policy
|
Retail
|
RETAIL2: Zoning laws and policies are implemented to encourage the availability of outlets selling fresh fruit and vegetables and/or access to these outlets, such as opening hours, or frequency of markets.
|
Policy
|
Retail
|
RETAIL3: The government ensures existing support systems are in place to encourage the promotion and availability of healthy foods in food retail outlets by improving the food choice environment through, for example, framing in promotion policies, choice of shelf placement, type of food that is displayed close to the cashiers.
|
Environmental determinants
|
Meso/Macro
|
Environmental Food Availability and Accessibility
|
Neighbourhood healthy food availability
|
Product
|
Extrinsic Product Attributes
|
Nutritional information
|
Micro
|
Portion Size
|
Portion size from manufacturers and food outlets in settings
|
Interpersonal determinants
|
Social
|
Household literacy level
|
Food literacy on the household level (composite score)
|
Individual determinants
|
Biological
|
Biological
|
Biological
|
Psychological
|
Psychological
|
Psychological
|
Behaviour outcomes
|
Behaviour
|
Dietary behaviour
|
Meal location
|
Behaviour
|
Minority group specific indicators
|
Changes in eating habit
|
Abbreviations: FUND, funding and resources; GOVER, governance; INEQUAL, Inequality; MONIT, monitoring and evaluation. These abbreviations were adapted from the INFORMAS FOOD-EPI domains (4)
|
Table 5. Physical activity and sedentary behaviour indicators that are not currently available in EU monitoring systems
Indicator dimension
|
Indicator domain
|
Indicator
|
Policy indicators
|
Physical environment
|
Active environments
|
Government supports prioritising integrated urban design and mixed land-use policies prioritising compact, mixed-land use in urban, rural and transport plans (MOVING M4.3).
|
Physical environment
|
Active environments
|
Government supports the increased provision of public transport (MOVING M4.2).
|
Physical environment
|
Active environments
|
Government supports increasing road safety actions for pedestrians, cyclists etc. (MOVING M4.5).
|
Society
|
Active Societies
|
Government supports financial incentives for individuals to promote physical activity (MOVING M1.6).
|
Funding and resources
|
Active systems
|
Interdisciplinary research funding - increase research capacity across all sectors on the rates of physical inactivity or activity and policy interventions.
|
Environmental determinants1
|
Worksite, workplace setting/Kindergarten, school, university setting
|
Availability/accessibility
|
Availability of outdoor activity space in kindergarten/university/workplace.
|
Worksite, workplace setting/Kindergarten, school, university setting
|
Availability accessibility
|
Availability of indoor activity space in kindergarten/university/workplace.
|
Interpersonal determinants
|
Home, neighbourhood, community setting/Worksite, workplace setting
|
Supportive behaviour by friends/parents/by partner/by colleagues
|
Proportion of people (all age groups) who receive significant social support from friends, colleagues, partners, parents, other relatives to be physically active.
|
Home, neighbourhood, community setting
|
Physical activity with parents
|
Proportion of children who conduct physical activity with their parents at least one hour per week (AdiMon D1.12).
|
Behaviour outcomes
|
Behaviour
|
Domain-specific sedentary behaviour
|
Sitting time at work/in kindergarten/school/university, during transportation in a car/bus and in leisure-time.
|
Behaviour
|
Non-organized sports/exercise participation
|
Non-organized sports/exercise participation.
|
Behaviour
|
Physical activity in kindergarten
|
Average active play time per day in kindergarten.
|
1 Measures for these indicators were found for the school level setting.
MOVING: A policy monitoring tool for physical activity created as part of CO-CREATE project (14). These indicators were taken from this tool.
AdiMON: A population-wide system to monitor the factors relevant to childhood obesity, created by the Robert Koch Institute (24)
|