10 years of HEPA Europe: what made it possible and what is the way into the future?

Eva Martin-Diener¹, Sonja Kahlmeier¹, Anne Vuillemin², Willem van Mechelen³, Tommi Vasankari⁴, Francesca Racioppi⁵, Brian W. Martin¹

¹ Institute of Social and Preventive Medicine, University of Zurich, Switzerland
² University of Lorraine, EA 4360 APEMAC, Faculty of Sport, France
³ Department of Public & Occupational Health and EMGO+ Institute, VU University Medical Centre, Amsterdam, the Netherlands
⁴ UKK Institute for Health Promotion Research, Tampere, Finland
⁵ World Health Organization Regional Office for Europe

Abstract

HEPA Europe, the European network for the promotion of health-enhancing physical activity, will have its 10^th annual meeting in 2014. Membership of the network has grown to 129 institutions from 32 countries. Collaborations have been established with the World Health Organization (WHO), the European Union (EU), Agita Mundo, the global network for physical activity promotion, other regional networks, and the International Society for Physical Activity and Health. Physical activity has moved up on the public agenda; in 2013 the EU Council adopted its first ever Council Recommendation in sport, notably on promoting health-enhancing physical activity, and in 2014 WHO has begun the development of a Physical Activity Strategy for the European region. HEPA Europe has had strong involvement in these developments despite the absence of a long-term funding mechanism, changing priorities within its supporting institutions and difficulties of earlier attempts to establish a European physical activity network. This article reflects on four groups of enabling factors for this development. 1) The time was right: favourable secular developments, products of previous work and the momentum of an international pioneer phase met with windows of opportunity in key institutions. 2) A combination of commitment and conceptual clarity: clearly defined objectives, structures and approaches provided opportunities for individual commitment to blossom. 3) Institutional support: structural attachment to WHO and steady support from a sequence of key institutions was provided. 4) The deliverance of high visibility products: HEPA Europe’s events, its working groups, as well as its tools met with great interest. In Europe, the HEPA network has found a role which is not filled by any other institution and which is increasingly in demand. To meet these growing and changing expectations, HEPA Europe will need to continue evolving. This will take dedicated individuals, supportive member institutions as well as sustainable funding mechanisms.

Zusammenfassung

HEPA Europe, das europäische Netzwerk für Bewegungsförderung, wird 2014 sein zehntes Jahrestreffen durchführen. Es zählt heute 129 Mitgliederinstitutionen aus 32 Ländern. Die Zusammenarbeit mit der Weltgesundheitsorganisation (WHO), der Europäischen Union (EU), Agita Mundo, dem globalen Netzwerk zur Bewegungsförderung, anderen regionalen Netzwerken und der internationalen Gesellschaft für Bewegung und Gesundheit (ISPAH) sind etabliert. Politisch hat das Thema Bewegung an Bedeutung gewonnen; 2013 gab die EU ihre ersten Sport-Empfehlungen heraus, nämlich zu gesundheitsförderlicher Bewegung, und 2014 nahm die WHO die Entwicklung einer Bewegungsförderungsstrategie für Europa in Angriff. HEPA Europe war an diesen Entwicklungen namhaft beteiligt; dies ohne längerfristige Finanzierungsmechanismen, trotz Veränderungen bei den Prioritäten seiner unterstützenden Institutionen und früherer Schwierigkeiten bei der Etablierung eines Netzwerks. Dieser Artikel reflektiert vier Gruppen von Faktoren, welche die Entwicklung von HEPA Europe begünstigten. 1) Die Zeit war reif: günstige gesamtgesellschaftliche Entwicklungen, die Früchte früherer Anstrengungen und der Schwung einer internationalen Pionierphase fielen zusammen mit günstigen Konstellationen in Schlüsselinstitutionen. 2) Kombination von Engagement und konzeptioneller Klarheit: klar definierte Ziele, Strukturen und Prozesse ermöglichten die Entfaltung individuellen Engagements. 3) Institutionelle Unterstützung: strukturelle Anbindung an die WHO und Unterstützung durch wechselnde Schlüsselinstitutionen waren wichtig. 4) Sichtbare Produkte: die Anlässe von HEPA Europe, seine Arbeitsgruppen und Instrumente trafen auf Interesse. HEPA Europe erfüllt eine Rolle in Europa, welche von keiner anderen Institution eingenommen werden kann und welche je länger je mehr gefragt ist. Um zukünftigen Erwartungen gerecht zu werden, muss sich das Netzwerk weiter entwickeln. Es wird dazu engagierte Fachleute, unterstützende Institutionen sowie nachhaltige Finanzierungsmechanismen brauchen.

HEPA EUROPE – where are we today?

In summer 2004, the launch of a European physical activity promotion network was decided during an expert meeting in Magglingen, Switzerland, with participants from European countries, the World Health Organization (WHO) and Agita Mundo, the global physical activity promotion network. After a one year preparation period, HEPA Europe, the European network for health-enhancing physical activity (HEPA) was officially founded at its first meeting on 26–27 May 2005 in Gerlev, Denmark (Martin et al., 2006). In August 2014, its 10^th annual meeting will take place in Zurich, Switzerland. In the meantime, membership of the network has grown to 129 institutions from 32 countries. Collaborations have been established with the WHO Regional Office for Europe, the European Union (EU), Agita Mundo, other regional physical activity promotion networks, and the International Society for Physical Activity and Health (ISPAH) (Martin and Kahlmeier, in press). These collaborations have for example contributed to the first ever EU Council Recommendation in the area of sport, notably on the topic of “promoting healthenhancing physical activity across sectors” (EU Council, 2013) and they are also playing a role in the development of a WHO European Physical Activity Strategy which has begun in early 2014 (WHO, 2013a). In a survey carried out between November 2010 and January 2011 in 482 members and other stakeholders of HEPA Europe from more than 30 countries, 49% reported that HEPA Europe’s activities or products had had an influence on physical activity promotion in their work, in their institution or at their national level (WHO, 2012). This development is remarkable for several reasons. Earlier attempts to establish a European physical activity network had failed. During the last decade, important member institutions of HEPA Europe have undergone changes in their priorities and were not able to continue the same level of support. And last but not least, it was not yet possible to establish a long-term funding mechanism for the network; public funding had to be secured from a series of different institutions, private funding has only played a minor role.
How was this development possible despite all these handicaps? Below we will reflect on enabling factors and will address the main challenges for HEPA Europe in the future.

Enabling factors

The time was right

There were several secular developments favouring the creation and the further development of the HEPA Europe network. The rise of obesity and non-communicable, lifestyle-related, diseases and the growing interest in population levels of physical inactivity are certainly to be listed in this context. Changes at the political level and developments in communication technology and transport had created and established new possibilities for collaboration at the European and at the global level.
HEPA Europe could build on previous work. A first European network based on a collaborative project supported by the European Commission had already made important conceptual contributions to the development of physical activity promotion since 1996, for example through cycling and walking (Martin et al., 2006). A follow-up project was not funded by the European Commission in 2001, but many of the contacts established through the network remained intact, and its previous leaders from the UKK Institute in Tampere, Finland became essential supporters of HEPA Europe.
In addition to the general scientific progress on the health effects and the intervention options for physical activity, relevant cornerstones at the global level were the 1996 report of the US Surgeon General’s Report on Physical Activity and Health (US Department of Health and Human Services, 1996), the work of the Physical Activity and Health Branch at the Centers for Disease Control and Prevention (CDC) in Atlanta in the following years, the development of Agita Mundo following the main event of WHO’s World Day for Health in 2002 on the topic of “Physical Activity for Health” in São Paulo, Brazil (Martin and Kahlmeier, in press), and important health policy documents such as WHO’s Global Strategy on Diet, Physical Activity and Health (WHO, 2004). Thus, HEPA Europe had the opportunity to use the momentum of an international pioneer phase in physical activity and health with great commitment and enthusiasm of many people active in the field, and with a general spirit of collaboration and mutual support in research, policy and practice.

There were institutional windows of opportunity in 2004. Through the successful Transport, Health and Environment Pan-European Programme (THE PEP) (Martin et al., 2004), solid working relationships had been established between WHO, a number of European countries and also the United Nations Economic Commission for Europe (UNECE). Key individuals within the Swiss Federal Offices of Sport and Public Health were not only supportive of the expert meeting held in Switzerland in 2004, but also of the actual development of HEPA Europe. And finally, WHO’s Regional Office for Europe was willing and ready to host the network.

Combination of commitment and conceptual clarity

Expertise and individual commitment are essential to make progress in any field of public health. However, only mutual agreement on objectives, structures and approaches allows combining the advantages of top-down and bottom-up approaches and making progress on a broader scale. Early on in its development, HEPA Europe defined its vision, aims and guiding principles. The development of the HEPA Europe framework and the network’s impact model were other
important steps.
The work of HEPA Europe is based on relevant policy statements of international bodies, such as the WHO Global Strategy for Diet, Physical Activity and Health (WHO, 2004) mentioned earlier. The Terms of Reference of HEPA Europe were drafted before and finalised at the first network meeting in 2005 (Martin et al., 2006). They have been adapted in detail since, but already in their original form they described the vision of the network, which is to achieve better health through physical activity among all people in Europe, its goals and objectives as well as its structures and functioning.
The first activities of HEPA Europe were to a large extent driven by available resources, knowledge and background of the active members, and by opportunities; they were less based on a formulated implementation strategy. In 2006, the Steering Committee started the development of an impact model for the network. In several steps six areas were identified which could be addressed with a good chance of success: social and physical environments for health-enhancing physical activity; cultural values regarding HEPA; recognition of benefits of HEPA by stakeholders and its role in health policy; evidence on effective interventions; HEPA-related workforce development; and coordination. At the annual network meeting 2008 in Glasgow, the HEPA Europe impact model was discussed and finalised with the network members (WHO, 2009). There was general agreement that the most promising and effective way for the network to address the causes of the physical inactivity problem would be to support indirect stakeholders such as NGOs or ministries. They could then address those stakeholders who are directly in power to change environments and systems (figure 1).
In parallel to the development of the impact model, the Steering Committee of HEPA Europe was also working on a framework to facilitate communication with decision makers and a wider audience on the principles and mechanisms of HEPA promotion at the population level. The HEPA Europe framework was based on existing models such as the public health action cycle (Institute of Medicine, 1988) and the model for policy research (Schmid et al., 2006), but it illustrated also the fact that programmes and activities can only work through the determinants of the respective domains of physical activity (figure 2). In addition, by integrating the societal context it acknowledged that in real life there are other factors, such as policies and interventions of other sectors, the social climate, or the economy which are heavily affecting all levels of HEPA promotion and often interact with specific public health interventions. Finally, the framework served to highlight the central role of the knowledge base, consisting of practical experiences and scientific evidence, for systematic progress in the field, with respect to all three types of evidence for public health (Brownson et al., 2009). 
Membership to HEPA Europe is open to institutions and organisations willing to contribute to the goals and objectives of the network. The number of members increased from 36 in 2006 to 129 in 2013, representing 32 countries. The majority of members are public institutions; they are active in research, physical activity and sports promotion, teaching, advocacy, policy development or health promotion in general. The members represent a range of sectors and expertise; they are listed on the HEPA Europe website (www.euro.who.int/hepaeurope) and in the reports of the annual network meetings (WHO, 2014). The Steering Committee of HEPA Europe has been composed by a total of 25 individuals from 13 countries since 2005 (table 1). Its members are elected for a one year term and can be re-elected. The chair has a two year term and can be re-elected once. Since 2009, the steering committee has a designated executive member.
The network’s working groups (table 2) have been important for the development of methods and guidance; they range from funded research and development projects to self-financed exchange of ideas on specific topics (Vuillemin et al., 2004). The working groups are open to members of HEPA Europe and of the other physical activity networks (Martin and Kahlmeier, in press) as well as to invited experts. Large groups can consist of more than 30 members; they usually have a core group driving the work forward. In early years, the Steering Committee played an important role in organising the working groups; in the meantime a total of some 25 volunteering experts from member institutions have taken over a lead.

Institutional support

Apart from issues of financial sustainability, one of the lessons from the first European physical activity network was that the secretariat of HEPA Europe should be better affiliated to an international organization with convening powers. The WHO Regional Office for Europe has included the network as part of its technical programme of work, first at its European Centre for Environment and Health in Rome and since 2012 at its Regional Office for Europe headquarters in Copenhagen. This has provided an organisational framework for HEPA Europe, but also multiple synergies with WHO’s other activities and direct connection with the work of health ministries in European member countries. Support was provided also by the other institutions represented in the HEPA Europe Steering Committee (table 1) and working groups (table 2). Very important were also the organisers of the annual meetings, symposia or conferences (table 3) and the hosts of the working group meetings and other events of the network. Organisations at the global level or from other world regions such as Agita Mundo, ISPAH (GAPA, 2010) or the American College for Sports Medicine with its Exercise is Medicine initiative have also been important partners.

Direct funding for HEPA Europe was provided in the first years by the Swiss Federal Offices of Sport and Public Health, in later years support was received from the ministries of Health of Italy, the Netherlands and Norway. Cooperation between WHO and the European Commission covered several projects in the range of activities and events of HEPA Europe, specific working groups were supported from different country sources.

High visibility products

HEPA Europe has given its members a platform to exchange their ideas, to contribute to the development of tools and guidance (Vuillemin et al., 2014) and to take part in their implementation. 
The number of participants at the annual network meetings has increased steadily. The conferences or symposia combined with the meetings since 2008 have further added to their attractiveness (table 3). Members of the network have played an important role in key publications in the field such as WHO’s “Physical activity and health in Europe: evidence for action” (WHO, 2006a) as well as in expert groups of WHO (WHO, 2006b; Branca, Nikogosian and Lobstein, 2007) and the European Union (EU, 2008).

Several of HEPA Europe’s working groups have organised separate events, most recently the WHO Expert Meeting on Physical Activity Promotion in Health Care Settings at the University of Zurich in 2013 (Martin, 2014). They have developed specific products such as the Health Economic Assessment Tool Walking and Cycling (www.euro.who.int/HEAT, Rutter et al., 2013), the HEPA Policy Audit Tool (www.euro.who.int/hepapat, Bull et al., 2014) and guidance and recommendations on a whole range of topics, including national physical activity recommendations (Oja et al., 2010), the role of sport clubs for health (Kokko et al., 2009) or physical activity promotion in socially disadvantaged groups (WHO, 2013b). A complete list of products of HEPA Europe and its working groups can be found in the reports of the annual network meetings (WHO, 2014).

The way ahead

Despite a number of challenges, HEPA Europe, the European network for health-enhancing physical activity, has been able to make a contribution to physical activity and health in Europe over the last ten years. The coincidence of a number of favourable developments during its nascency, the combination of commitment and conceptual clarity, institutional support at several levels and the network’s ability to produce high visibility output in a timely fashion have made this
possible.
Analyses of inter-organisational networks have described a number of factors as important for the effectiveness of collaborative partnerships (Broesskamp-Stone 2012). They include favourable contextual factors, access to technical expertise, vision, goals and objectives which are clearly defined, supported and updated when necessary, processes which are accepted by all network members, adequate resourcing and community involvement. With HEPA Europe, all these elements are present. As the network has not been “commissioned” by any national or international institution, but has grown out of the initiative of concerned experts, technical expertise and community involvement are built into it. However, fund-raising remains a challenge. In this context, high visibility products have become an additional success factor. Overall, in its different activities HEPA Europe shows characteristics of all three types of inter-organisational networks (Broesskamp-Stone, 2012): obligational, promotional and systemic.
In the European region of 2014, the role of physical activity for health is increasingly recognised not only within public health, but also in the sport sector, and important developments are underway regarding population wide physical activity promotion. Accordingly the demand for evidence-based know-how has grown, as has competition in the field, but no other institution currently has the same profile as HEPA Europe (Kahlmeier et al., 2014). To meet these growing and changing expectations, the network will have to continue evolving. Close and systematic exchange with its members and other stakeholders is essential for this purpose, as flexibility in its structures and new elements such as the communication strategy currently under development. The generation of HEPA Europe pioneers will have to be replaced by committed individuals in the steering committee and in the working groups of the network, but also in its partner organisations. Priorities within HEPA Europe’s member institutions will continue to change and evolve, so funding and other forms of institutional support will have to be secured from current as well as from new members and partners.

Acknowledgements

The authors wish to thank all the individuals and institutions which have supported HEPA Europe. The views expressed are solely the authors’ and do not necessarily relect those of the World Health Organization.

Corresponding author:

Eva Martin-Diener, Institute of Social and Preventive
Medicine, University of Zurich, Hirschengraben 84,
CH-8001 Zürich, Phone +41 44 634 5001,
E-Mail: eva.martin@ifspm.uzh.ch

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