We gathered data about national systems that monitor PA/SB/SP of the adult population from all 27 countries in the EU. We identified different systems, but only analysed national, and not regional systems, and only included systems that were not a part of multinational surveys (e.g., EHIS). The main results of this study are: 1) PA, SB and SP of adults are still not being systematically monitored in 11/27 EU countries, while only 8 Member States are monitoring all three behaviours; 2) only the Netherlands, Portugal and Slovenia hold monitoring systems that encompass all three behaviours while covering most of the domains and dimensions of PA/SB/SP; 3) measurement tools being used show large heterogeneity across the countries with established monitoring systems; and 4) existing monitoring systems typically rely on PA questionnaires, while device-based assessment of PA/SB is scarce.
Although international surveillance systems enable between-countries comparisons, they typically lack detail and fail to consider cultural context of a specific environment. To this end, national systems that consider specific cultural contexts are needed for optimal policymaking. In a recent comprehensive analysis performed by the WHO, almost all EU Member States have been identified as having at least one surveillance system for PA [16]. In contrast, by excluding EU-wide surveillance (e.g., EHIS), and by insisting on more stringent inclusion criteria for surveillance (i.e., by including only systematic collection, analysis and interpretation of the health-related data and not sporadic, individual research studies) this study found that only a little over half of EU countries systematically monitor at least one of the concepts related to PA. Some of these monitoring systems date back to the twentieth century, as early as 1964 (Denmark) and 1973 (Slovenia), but most of the countries started monitoring PA in the 2000s. The growth of PA monitoring systems in EU coincides with an increase in PA promotion and other health-enhancing initiatives and policies [3, 4, 6,7,8]. Nevertheless, 11 Member States are forced to rely exclusively on estimates coming from EU-wide surveillance systems in the policy creation and policy evaluation process. These systems do not provide any information on domains or dimensions of PA, they typically lack detailed estimates across regions, and they are run only every 5–6 years. Although EU-wide systems are vital for policy making at the EU level, all these limitations impede their use for timely and efficient policy-making at a national level. In conclusion, much work is ahead if systematic and detailed surveillance of PA-related behaviours on a national level is to be achieved across the whole EU.
Next, we found that more than one half of existing surveillance systems exclude individuals older than 80 years. Considering that more than 27 million people older than 80 were living in the EU in 2016 [18], and that the share of elderly people has been projected to continue increasing, it is of paramount importance to also include the oldest age groups in the surveillance of PA/SB/SP. Besides the well-known benefits of PA for cardiovascular and metabolic health, in older adults PA has a vital role in the prevention of falls and falls-related injuries as well as in declines in bone and cognitive health.
Surveillance systems identified through this study typically included several domains of PA, most commonly leisure time and transport domains. At the same time, these two domains are the ones most amenable to interventions. With regard to the dimensions of PA, duration and frequency are being reported far more often than intensity. Although intensity of PA is the dimension that is the most difficult to assess, its importance has been repeatedly highlighted [19,20,21]. Unfortunately, even though the information about PA of different intensity is obviously available (e.g., from the IPAQ questionnaire), many surveillance systems fail to analyse and report these data. SB is monitored less frequently than PA, despite recent research showing the downsides of high SB and its deleterious effects on health [22,23,24]. Even when assessed, SB is typically conceptualised through only one dimension, mostly sitting, without any effort made to distinguish the context (e.g., watching TV, reading, playing, etc.). Given the accumulating evidence that unique sedentary behaviours relate to different health outcomes, including a number of SB dimensions should be encouraged. Next, in line with the recently introduced paradigm of 24-h movement guidelines [25], optimal surveillance should strive to include both PA and SB, while also assessing sleep. As global or EU-wide health surveillance systems (e.g., The Global Health Observatory, The European Health Interview Survey) do not include information on sleep duration, and since we did not collect data on sleep for national surveillance systems included here, it was not possible to identify countries in the EU that monitor all movement behaviours and are therefore able to assess compliance with the 24-h movement guidelines. Still, as we identified only 10 Member States that are monitoring both PA and SB, such estimates are evidently still not possible in the larger part of the EU.
Even though it has been well established that device-measured PA and SB are more reliable and valid compared to self-report [26,27,28], nearly all 16 EU countries with established national surveillance systems are relying exclusively on self-report for monitoring PA and SB, probably because they are economically and logistically more suitable for large surveys. Only three countries have reported monitoring PA with accelerometers (Finland, Ireland and Portugal). Yet, these assessments are not being performed on a regular basis and include a rather small number of participants. At the same time, several population-based research studies that had been set-up in the last few years and assessed PA via accelerometers in > 100,000 individuals, have shown that device-measured PA is feasible even on a large scale (e.g., UK Biobank study). Of note, the availability of device-based measures does not mean that the use of self-report methods should be discontinued. On the contrary, device-based assessment methods for PA/SB need to be accompanied with questionnaires that cover a wide range of domains and contexts of these behaviours in order to ensure the detail and the granularity of the data needed for data-informed policy making [29].
Surprisingly, many countries that have opted to perform cross-cultural adaptation of the existing questionnaires, have failed to confirm their measurement properties after the process. The fact that most countries are using questionnaires of unknown validity and reliability undermines the trustworthiness of conclusions based on the collected data and hampers the evaluation of the effectiveness of related policy measures.
Our study has several strengths. This is the first study to offer a very extensive overview of national surveillance systems for several movement-related behaviours across EU. First, we collected detailed data from all EU countries. Second, we extended our focus from PA to include other behaviours related to energy expenditure such as SB and SP. Finally, we analysed details such as domains and dimensions for all three behaviours.
Still, this study is not without limitations. First, despite several attempts we have not been able to contact seven countries via an online questionnaire (Belgium, Denmark, Finland, Germany, Greece, Slovakia and Spain), so the data had to be extracted from earlier studies or received through contact with independent national experts. As a result, some information for these 7 Member States might be incomplete or outdated. Second, we asked for details on the dimensions and domains of PA, but did not gather data on the type of PA. Hence, it was not possible to determine the extent to which national surveillance systems are able to evaluate muscle strengthening and balance elements of PA recommendations. Third, although we collected very comprehensive data on systems that monitor three distinct behaviours (i.e., PA/SB/SP), we did not request information on sleep surveillance. Consequently, we were not able to identify countries in the EU that are capable of evaluating adherence to the 24-h movement guidelines.