Expert meeting on improving drinking-water consumption for decreasing the intake of sugar-sweetened beverages and reducing plastic waste: meeting report, 27-28 February 2020, Moscow, Russian Federation

Expert meeting on improving drinking- water consumption for decreasing the intake of sugar-sweetened beverages and reducing plastic waste Meeting report 27-28 February 2020 Moscow, Russian Federation Abstract Document number: WHO/EURO:2021-3465-43224-60576 © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. This publication contains the report of the Expert meeting on improving drinking-water consumption for decreasing the intake of sugar-sweetened beverages and reducing plastic waste. Meeting Report, 27-28 February 2020, and does not necessarily represent the decisions or policies of WHO. A meeting on the promotion of drinking-water consumption was held in Moscow on 27-28 February 2020, hosted by the WHO European Office for the Prevention and Control of NCDs in Moscow, Russia, and co-organized by the WHO European Centre for Environment and Health, Bonn, Germany. The interdisciplinary meeting was attended by 22 participants, including experts from national and local authorities from seven Member States, the European Commission, academia and nongovernmental organizations. Seven sessions were held on the topic of drinking-water promotion in the Region over the two-day meeting. The meeting aimed to strengthen the understanding of tap water consumption patterns in selected cities, regions and countries and the identification of opportunities, barriers and challenges to promote the consumption of drinking-water. It provided an important platform to share experiences, learn from good practice examples and identify solutions in promoting the consumption of drinking-water. Expert input from the meeting will lead to the development of a toolkit to support the promotion of drinking-water for local decision-makers. iii Contents ACKNOWLEDGEMENTS .............................................................................................................................................. IV EXECUTIVE SUMMARY ............................................................................................................................................... IV BACKGROUND ............................................................................................................................................................ 1 MEETING OBJECTIVES AND STRUCTURE ..................................................................................................................... 2 SUMMARY OF SESSIONS ............................................................................................................................................. 3 SESSION 1: TAP WATER CONSUMPTION IN THE WHO EUROPEAN REGION ...................................................................... 3 SESSION 2: EXAMPLES OF AND EXPERIENCES WITH CAMPAIGNS ON TAP WATER PROMOTION ......................................... 4 SESSION 3: TOOLS AND CRITICAL INFORMATION FOR THE PROMOTION OF TAP-WATER CONSUMPTION ........................... 5 SESSION 4: REGIONAL AND LOCAL EXPERIENCES - ONGOING AND PLANNED ACTIVITIES ................................................ 6 SESSION 5: KEY BARRIERS AND POTENTIAL SOLUTIONS FOR TAP WATER PROMOTION .................................................... 7 SESSION 6: NEXT STEPS AND COMMITMENTS IN PILOT COUNTRIES.................................................................................. 9 ANNEX I ..................................................................................................................................................................... 10 LIST OF PARTICIPANTS ............................................................................................................................................... 10 ANNEX II .................................................................................................................................................................... 13 MEETING AGENDA ..................................................................................................................................................... 13 iv Acknowledgements The WHO Regional Office for Europe wishes to thank the following contributors whose knowledge and expertise made the compilation of this report possible. This report is a result of an interdisciplinary collaboration between the WHO European Office for the Prevention and Control of NCDs in Moscow, Russia, and the WHO European Centre for Environment and Health in Bonn, Germany, and is based on materials presented and discussed in the expert meeting on improving drinking-water consumption for decreasing the intake of sugar- sweetened beverages and reducing the environmental footprint of bottled water. Development of this report was guided by João Breda and Kremlin Wickramasinghe, WHO European Office for the Prevention and Control of NCDs along with Oliver Schmoll, WHO European Centre for Environment and Health. Significant contributions were provided for note taking, reviewing and following up with participants by Charlotte Bunge, Edwin Kwong, Lea Nash, Stephen Whiting, Holly Rippin, WHO European Office for the Prevention and Control of NCDs; Karin Geffert and Valentina Grossi, WHO European Centre for Environment and Health; and Keeva Duffey, WHO Regional Office for Europe. We would like to acknowledge the participants, temporary advisors and experts who attended this meeting who provided valuable inputs. The findings of the meeting are instrumental for the work of WHO/Europe to support its Member States in promoting the consumption of drinking-water for health and environmental gains. All the activities related to this report were funded through a grant from the Government of the Russian Federation in the context of the WHO European Office for the Prevention and Control of NCDs and RD’s funds for interdivisional activities (2019). Executive summary Noncommunicable diseases (NCDs) account for 86% of all deaths in the WHO European Region. There is profound evidence that a greater consumption of sugar-sweetened beverages (SSBs) is associated with an increase in NCDs and associated risk factors, such as diabetes type 2 and obesity. SSBs are commonly consumed by children and thereby adding to the rise in childhood obesity. Therefore, replacing the consumption of SSBs with drinking-water is a key intervention in tackling NCDs and achieving the target of a 25% reduction in premature death due to NCDs by 2025. Furthermore, the promotion of drinking-water plays a crucial role in achieving the 2030 Agenda for Sustainable Development. Despite that drinking-water is the healthiest and cheapest choice for hydration, with the lowest environmental footprint, the consumption of bottled water has risen in the last few years. The rise of bottle water consumption is linked to CO2 emissions and plastic waste generation that could be mitigated by the use of tap water. Water intake patterns differ widely between and within the countries of the WHO European Region, suggesting a multicomponent and multisectoral approach. To address this, the European Office for the Prevention and Control of NCDs and the European Centre for Environment and Health of the WHO Regional Office for Europe convened a two-day multi-stakeholder meeting in Moscow, Russian Federation, which aimed to obtain expert inputs for the development of a toolbox to support local decision-makers in the promotion of drinking-water in key settings, while reducing the consumption of SBBs and environmental footprint. The meeting was attended by 22 participants, including experts from national and local authorities from seven Member States, the European Commission, academia and nongovernmental v organizations (NGOs). The meeting aimed to share experiences and assess the opportunities, barriers and challenges of existing initiatives for the promotion of drinking-water consumption from the tap in selected cities, regions and countries. This report provides an overview of the main learning points of the meeting and next steps for the development of a comprehensive toolkit on drinking-water consumption. 1 Background Noncommunicable diseases (NCDs) account for 86% of all deaths in the WHO European Region. Increase in consumption of sugar-sweetened beverages (SSB) is associated with an increase in NCDs and associated risk factors, such as diabetes type 2 and obesity, especially in children. For example, people who consume sugary drinks regularly – 1 to 2 cans a day or more – have a 26% greater risk of developing type 2 diabetes than people who rarely consume such drinks.1 Furthermore, the rise in childhood obesity can be contributed to the increase in SSB consumption, as data from 23 countries discovered that around 1 in 10 children in the Region consumed soft drinks (9.4%).2,3 Therefore, replacing the consumption of SSBs with drinking-water is a key intervention in tackling NCDs and achieving the target of a 25% reduction in premature death due to NCDs by 20254. Compared to bottled water, drinking-water from taps can have a up to 300 times smaller ecological and carbon footprint, because it does not require packaging materials (ranging from plastic to glass, aluminium or steel cans), nor long transport routes across different countries and continents, with corresponding emissions..5,6 However, the consumption of bottled water has risen in the last years due to several factors.7 Access to safe, sufficient, affordable and acceptable drinking-water is not only critical to human health and well-being, but also a basic human right. In the WHO European Region, the Protocol on Water and Health, a legal, multilateral instrument jointly serviced by the United Nations Economic Commission for Europe and the WHO Regional Office for Europe, supports countries in achieving access to drinking-water for all in all settings. The Protocol is underpinned by regional policy commitments, such as the Declaration of the Sixth Ministerial Conference on Environment and Health.8,9 Furthermore, the promotion of drinking-water plays a crucial role in achieving the Sustainable Development Goals 2, 3, 4, 6 and 12.10 Therefore, the promotion of drinking- water needs to be regarded as a public health mission given the multiple co-benefits for health, climate change and the environment, as well as a beneficial impact on overcoming inequality and inequity. Water intake patterns differ widely between and within the countries of the WHO European Region. Strategies that aim at increasing drinking-water consumption from taps need to address multiple components that are tailored to the national and local context, ranging from adapting regulations at national level to advocacy campaigns at local levels. 1 World Health Organization. Taxes on sugary drinks: why do it? 2017; https://apps.who.int/iris/bitstream/handle/10665/260253/WHO-NMH-PND- 16.5Rev.1-eng.pdf?sequence=1 2 Williams J, Buoncristiano M, Nardone P, et al. A Snapshot of European Children's Eating Habits: Results from the Fourth Round of the WHO European Childhood Obesity Surveillance Initiative (COSI). Nutrients. 2020;12(8):2481. Published 2020 Aug 17. doi:10.3390/nu12082481 3 Scharf RJ, DeBoer MD. Sugar-Sweetened Beverages and Children's Health. Annu Rev Public Health. 2016;37:273-93 4 Action Plan for the Prevention and Control of Noncommunicable Diseases in the WHO European Region 2016–2025. Copenhagen: WHO Regional Office for Europe; 2016. http://www.euro.who. int/__data/assets/pdf_file/0008/346328/NCD-ActionPlan-GB.pdf 5 Botto, S. Tap Water vs. Bottled Water in a Footprint Integrated Approach . Nat Prec (2009). https://doi.org/10.1038/npre.2009.3407.1 6 Fantin, V., Scalbi S., Ottaviano G., Masoni P. A method for improving reliability and relevance of LCA reviews: The case of life-cycle greenhouse gas emissions of tap and bottled water,Science of The Total Environment,Volumes 476–477, 2014,Pages 228-241, ISSN 0048- 9697,https://doi.org/10.1016/j.scitotenv.2013.12.115. 7 Tosun, J, Scherer, U, Schaub, S, Horn, H. Making Europe go from bottles to the tap: Political and societal attempts to induce behavioral change. WIREs Water. 2020; 7:e1435. https://doi.org/10.1002/wat2.1435 8 Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes. United Nations; 1999. http://www.unece.org/fileadmin/DAM/env/documents/2000/wat/mp.wat.2000.1.e.pdf 9 Declaration of the Sixth Ministerial Conference on Environment and Health. WHO Regional Office for Europe; 2017. https://www.euro.who.int/__data/assets/pdf_file/0007/341944/OstravaDeclaration_SIGNED.pdf 10 Sustainable Development Agenda. United Nations; 2015. https://www.un.org/sustainabledevelopment/development-agenda/ 2 Meeting objectives and structure The meeting took place on the premises of the WHO European Office for the Prevention and Control of NCDs in Moscow, Russian Federation, on 27–28 February 2020. Experts from national and local authorities, academia and NGOs were invited to present on current initiatives in the field of drinking-water promotion (see Annex 1 for full list of participants). Over the course of the two days, seven sessions were held to address the meeting aims of collating expert input in the development of a toolkit for local decision-makers to support the promotion of drinking-water. The meeting was considered as a sounding board to share experiences from cities, regions and countries, learn from good practice examples and identify opportunities and barriers for promoting the the consumption of drinking water (see Annex 2 for the meeting agenda). The objectives of the meeting were to: • Understand and identify the opportunities and challenges for promoting the consumption of drinking-water; • Appreciate the needed improvements in the enabling environment to facilitate the consumption of drinking-water from taps and reduce consumption of SSBs and the environmental footprint of bottled water consumption; • Identify support needs of countries, regions and cities to promote and increase the consumption of drinking-water from taps in key settings; • Identify success stories for promotion of tap water consumption in key settings; • Assess the existence of national or subnational surveillance mechanisms on drinking water consumption; • Identify national experts on water promotion and foster collaboration and exchange. Drinking-water can be defined as “water which is used, or intended to be available for use, by humans for drinking, cooking, food preparation, personal hygiene or similar purposes”.11 Drinking- water can be provided by piped supply systems (typically centrally treated) with one or more taps in the household, or by a point source (e.g. a well or spring) from which community members collect water manually and store it at home. For the purpose of the meeting it was agreed to use the definition of water available at home at the point of consumption, regardless of its origin; this excludes, however, bottled or other packaged water. Safe drinking-water does not represent any significant risk to health over a lifetime of consumption, including different sensitivities that may occur between life stages. Only consistently safe and acceptable drinking-water will enjoy the confidence and trust of the population and is the basis for promoting its consumption. Drinking-water is consumed widely in the WHO European Region; however there are remarkable differences between and within countries. Overall, information on this topic is sparse, in particular in eastern European or central Asian countries. There are different challenges related to data collection on tap water consumption, both from methodological and organizational aspects. Several initiatives have yielded good experience with the successful promotion of drinking-water in general or tap water in particular, all of which aid in decreasing the intake of SSBs and reducing the environmental footprint related to bottled water consumption. Successful approaches address 11 Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes. Geneva: United Nations Economic Commission for Europe and WHO Regional Office for Europe; 2006 (http://www.euro.who. int/en/publications/policy- documents/protocol-on-water-and-health-to-the-1992-convention-on-the-protection-and-use-of-transboundary-watercourses-and-international-lakes, accessed 18 July 2019). 3 context-specific factors and target groups needs and beliefs while using education or awareness campaigns. Experiences from the different settings differ, but four major barriers to drinking- water consumption from taps were identified and discussed in detail: • Concerns about water safety; • Dissatisfaction with taste or other organoleptic properties (including smell, appearance); • Mistrust in water service providers; • Acceptability and availability of drinking-water points. The meeting closed with the agreement of participants to develop a toolkit for local-level applications on the promotion of drinking-water consumption from taps (and other sources) for decreasing the intake of SSBs and reducing plastic waste and other environmental impacts. Summary of sessions Session 1: Tap water consumption in the WHO European Region Karin Geffert, WHO European Centre for Environment and Health, presented the findings of a review of the available evidence related to tap water consumption, data collection methods, key drivers for tap and bottled water consumption, barriers and enablers in key settings, as well as tap water promotion campaigns. The review was useful to investigate two strands of work: one on the proportion of tap water consumption and data collection in the Region, another on the key factors influencing beverage consumption. Key findings • Evidence on drinking-water consumption varies across the Region and there is no consistent data available. • The available information indicates that in several countries tap water represents the highest share of daily water intake, mainly in northern European countries (highest in Norway and Sweden), and some countries have a remarkably low share of tap water consumption, in particular in central and western European countries, such as Germany. • Personal and environmental factors play an important role in the choice of fluid source. • Women, children, people with self-perceived low health status and vegetarians tend to drink more tap water than bottled water. • Different settings may have an influence on consumption patterns (i.e. rural vs. urban areas, restaurants vs. households). • The main barriers for tap water consumption are the lack of access to safe drinking-water; health or taste concerns; dissatisfaction and mistrust with either tap water or the water service provider. Cultural or customer preferences also play a role. • Tap water initiatives exist in the Region with one or several of the following components: promoting access to and/or free provision of safe tap water; educational activities on the quality of tap water; active promotion and reminders to drink; provision of water fountains and toilet facilities; raising awareness at all levels on the impact of good hydration; implementation of supporting policies and evaluation of the activities. 4 • Enablers and barriers for key settings (such as schools, restaurants, healthcare facilities or nursing homes) were identified and discussed. Conclusions To successfully promote the consumption of drinking-water, a multicomponent approach should be chosen and adapted to settings, populations and contexts across the Region. There is a need for establishing consistent monitoring to assess drinking-water consumption patterns in general, as well as possible success of initiatives in promoting drinking water. Regarding water promotion campaigns, proper planning, monitoring and evaluation of the process and outcomes are important to understand the impact of the intervention. Results and lessons learned should be published to help other stakeholders enhance their initiatives to increase tap water consumption. Session 2: Examples of and experiences with campaigns on tap water promotion This session aimed to give an overview of good practice examples of promoting tap water, implemented in different countries and by different stakeholders from governments to NGOs. Three experts presented best practice examples and experiences with their campaigns on drinking-water promotion. • Karen Watson, Imperial College London, presented on a social marketing campaign for the promotion of water consumption called Drink Up! in the United States. • Samuel Höller, NGO “A Tip:Tap”, provided examples of campaigns at the local level and collaborations with water providers in Germany. • Krisztina Toth, National Institute of Pharmacy and Nutrition, Hungary, presented on the project HAPPY (Hungarian Aqua Promoting in the Young), a water promotion activity in school settings. Key findings • The use of messaging on multimedia platforms involving popular influencers to disseminate messages based on commercial market research data on purchasing behaviours of the population has proven to be successful. • Collaboration with local governments and local water suppliers supports the sustainable implementation of promotion initiatives. • Strengthening education and promotion can take place in various settings like schools, workplaces and in public spaces. For long-term behaviour change, special attention should be paid towards initiatives addressing children. • Providing public information and communication via social media and other communication channels (e.g. phone hotlines) supports trust-building in the community. • Improved access to tap water in public places and institutions via refill stations/tap water dispensers can be established at low effort and cost. • Advocacy towards legislative changes to increase water consumption and decrease SSB consumption in schools and public catering support long term behaviour change. 5 Conclusions Context specific conditions influence the patterns of water consumption and therefore require distinct approaches tailored to each local/national context. Education and awareness raising for drinking-water consumption benefits were deemed effective across all campaigns. Session 3: Tools and critical information for the promotion of tap-water consumption The session aimed to provide information about existing tools for the promotion of tap water, as well as data collection methods for assessing tap water consumption. Presentations were made on the following existing tools and assessments • Valentina Grossi, WHO European Centre for Environment and Health, presented on the recommendations of the WHO publication Improving health and learning through better water, sanitation and hygiene in schools (2019), an information package for school managers, teachers and school health staff to facilitate access to and sustainable management of water, sanitation and hygiene in schools. • Stefan Storcksdieck genannt Bonsmann, European Commission, Joint Research Centre Science for Policy, presented the toolkit How to promote water intake in schools on collating evidence on successful drinking-water promotion campaigns. • Joan Gandy, British Dietetic Association, presented on the relevance of fluid intake assessment methods, including the British Dietetic Association Fluid intake assessment (see also the article: Relevance of assessment methods for fluid intake). Key findings • Provision of drinking-water provides many health and education benefits to school children. • Practical actions to increase drinking-water consumption may include active promotion of free access to drinking-water in schools, and the establishment of a healthy school policy with a focus on good hydration practices. • Effective interventions to promote water intake in children should include multiple levels and components, engage stakeholders, anticipate barriers, monitor, evaluate and assess impact. • The amount of fluids consumed during and between meals varies between countries. • Several key issues with the assessment of fluid consumption were identified, namely water being excluded from surveys and challenges to estimate the volume consumed directly from the tap. • Several factors should be considered when choosing a methodology for estimating fluid/tap water intake, including the characteristics of study population, aim of measurement, whether it is a validated and reliable methodology and the resources available (finance, time, trained personnel, etc.). • The European Food Safety Authority suggests using two phone calls assessing the intake within the last 24 hours on different days of the week, including weekdays and weekends, although there is still no evidence that this is the most appropriate methodology to capture tap water consumption. 6 Conclusions Existing evidence-based guidance toolkits are available for policymakers and stakeholders who plan to implement well-planned interventions in school settings. Various challenges were noted in the data collection on consumption of tap water intake at national and local levels. It is recommended that future methodologies to assess water intake should be more pragmatic and applicable throughout the Region. Session 4: Regional and local experiences - ongoing and planned activities This session aimed to feature case examples of ongoing and planned activities related to tap water promotion. This session consisted of a panel discussion moderated by Oliver Schmoll and Kremlin Wickramasinghe. The panel of presenters included: • Rainer Aavik, Deputy Mayor of Pärnu City Government, presenting the Pärnu Development Plan for 2035; • Anne Marie Carr, Health Improvement Specialist of the UK Healthy Cities Network, presenting on the availability and accessibility of tap water for populations across the life course; • Pirous Fateh-Moghadam, Autonomous Province of Trento in Italy, presenting an outline of the public health surveillance programme “PASSI” (Progressi delle Aziende Sanitarie per la Salute in Italia [Progress of health authorities for the health in Italy]) and the options to include tap water related questions; • Snezana Barjaktarovic-Labovic, Primary Health Care Center, Bar, Montenegro, presenting the experience from Montenegro on the promotion of tap water; • Maral Tleulesovna Rakhimzhanova and Aigerim Nabievna Sadubaeva, Ministry of Health, Kazakhstan, presenting the situation in Kazakhstan regarding tap water consumption barriers. Key findings • A variety of approaches to influence water consumption was presented, including ensuring high-quality water and sewage solutions and educating youth about the importance of drinking tap water. • Education on health and environmental benefits of tap water consumption was recommended to support early healthy habits in children. • Strategies to make drinking-water appealing, freely available and accessible, along with access to online sources to navigate where free tap water is provided in local restaurants have proved successful. • Increase visibility, accessibility and opportunity to drink tap water in public spaces contributes to reducing SSB intake. • Decrease visibility, desirability and accessibility of SSBs (and bottled water) via regulatory measures, such as controls on advertising, prohibiting sales and/or introduction of a sugar tax to force reformulation of sugary drinks and reduce consumption. • Increase desirability of tap water by addressing the design, placement, perceived hygiene of water refill stations and public water fountains. 7 • Medical doctors and healthcare professionals can play an important role in the promotion of tap water consumption with patients. • Perceptions of risk associated with drinking-water influence consumption behaviours patterns, along with safety concerns and/or (mis)trust in governmental institutions and service providers. • Creating a (eco) label for specific facilities (i.e. restaurants, caterers) may increase consumers’ confidence in ordering tap water from these facilities. • Multi-stakeholder communication campaigns may target at and involve, for example, the general population, students, tourists, governmental departments, restaurants, event organizers and private companies. • Usage of social media and website campaigns on water quality was recommended, including testimonials in the local area. • High consumption of bottled water is linked to powerful advertising of bottled water producers in the country. • Challenges exist of bringing together government organizations and NGOs to work together on the promotion of tap water consumption. NGOs involved in the field of health and environment generally work independently and there are not enough experts and people with knowledge on the importance of tap water consumption who work in and with the government. • In communication campaigns on tap water consumption, it is important to explain the difference between the palatability and the safety of tap water, as many people tend to judge the safety of tap water directly on the basis of taste. • Different water sources differ in taste due to different minerals and organic properties; however, these different compositions do not affect the safety of the water. The WHO Guidelines for Drinking-water Quality thus do not recommend specific compositions of minerals in the water that are considered as healthy. They only define guideline values for chemicals that may harm the health of the consumer. Conclusions Understanding the different motivators and levels of change for different settings and cohorts of people is important in promoting tap water intake. A variety of strategies and approaches that tackle the intricacies in tap water consumption behaviour is important, especially addressing the perceptions in drinking tap water in the local context via different communication channels such as social media. Differences in perceptions of taste and safety of water will vary across the contexts and is important to acknowledge when promoting tap water consumption. Session 5: Key barriers and potential solutions for tap water promotion Participants were invited to take part in a group work session to discuss the identified barriers and solutions divided by topic: • Water quality and safety • Dissatisfaction • Mistrust • Acceptability and availability 8 All groups were asked to consider existing case examples, feasibility aspects (short and long term), stakeholders to involve and applicability and acceptability of initiatives. General discussion • There was consensus that public awareness should be raised about the benefits of tap water consumption, including the fact that it is cheap and safe. Education strategies should aim to dispel myths and misconceptions and educate about the relationship between appearance and taste and the safety of tap water. • A comprehensive strategy is needed to overcome the mistrust in drinking-water that can arise from distrust of government authorities and/or strong advertising influence from water filter manufacturers and sellers • Suggestions have been made to establish public rules, including the obligation to offer free tap water in private businesses, such as hotels, restaurants, cafés and bars. In order to make access to tap water free of charge, mechanisms such as financial compensations, means of rewards, incentives, certificates, labels, or official recognition should be considered. • Laws for the provision of free tap water in restaurants implemented in some countries of the WHO European Region and its effectiveness were highlighted as good practice examples. • The provision of drinking-water in all areas is becoming increasingly important in the context of increasing heatwaves due to climate change. Water quality and safety of water • The importance of being aware of the level of public concern about the assumed negative health effects of pharmaceuticals in tap water was highlighted. • There is uncertainty among consumers about the health impact of chlorine residues in tap water.. There is a distinguishable difference in the taste perception of chlorine residues between and within countries. • Awareness should be increased that mineral content of the water does not necessarily influence its safety. • People’s perceptions and misconceptions about whether hard or soft tap water is “better” to consume need to be addressed through information campaigns. However, it was noted that potential barriers could arise due to concerns that high concentration of calcium and magnesium in water displaces normal dietary intake, although there is no evidence for this. Design and maintenance of public water points • The availability of accessible and barrier-free water fountains in public places and buildings should be increased so that people can drink directly from them and fill up reusable bottles. • Design of water fountains needs to be user-friendly and attractive for individuals to use, considering an appealing design and appropriate distance between mouth and fountain and other adequate hygiene standards. There is a need to establish guidelines for water fountains to ensure such requirements. • Maintaining and cleaning the publicly available water fountains can be the task of the local water supplier. 9 • Provision of drinking-water should go hand in hand with clean sanitary facilities as people tend to avoid drinking water from a bathroom facility which does not meet hygienic standards. • It is important to ensure free access to clean and safe public toilet facilities. This increases their acceptability and usage, and thus improves public trust. Stakeholder engagement • Social media campaigns, health ambassadors (such as famous actors, singers and celebrities) and government officials could be involved in the promotion of drinking-water consumption, along with using mobile apps to remind people to stay hydrated. • The involvement of other actors such as health insurances as strong and trustworthy partner can be beneficial. • The role water filter manufacturers and sellers was discussed, particularly in terms of the extent to which their large advertising and marketing campaigns may hinder the promotion of tap water consumption. • Providing water service providers with certificates issued by government agencies (or other trusted bodies) proving that the production of drinking-water is quality-controlled is considered as a promising approach to combat mistrust. Session 6: Next steps and commitments in pilot countries Discussions during the two-day meeting demonstrated a wide range of opportunities but also barriers, as well as regional differences, which need to be addressed in the promotion of drinking- water consumption to decrease the intake of SSBs and environmental impact. Interdisciplinary and multisectoral action at the city, municipal and national level play an important role in enabling the implementation of drinking-water promoting strategies. Participants highlighted the need to improve diets and reduce consumption of SSBs through the promotion of drinking-water. The following next steps were agreed with participants: • Support the development of a good practice toolkit to promote drinking-water consumption and decrease consumption of SSBs; • Review the toolkit and pilot implementation at the subnational and municipal levels; • Review the preliminary list of identified challenges and solutions presented at the meeting; • Provide case studies for inclusion in the toolkit to support country implementation and share good practices from the Region. 10 Annex I List of participants Hungary Krisztina Toth National Institute of Pharmacy and Nutrition Hungary Kazakhstan Maral Tleulesovna Rakhimzhanova Head Department for the Prevention of Noncommunicable Diseases and Object Control Committee for Quality and Safety of Goods and Services Ministry of Health Kazakhstan Aigerim Nabievna Sadubaeva Chief expert Department of Public Health Protection Policy Ministry of Health Kazakhstan Montenegro Snezana Barjaktarovic Specialist in hygiene and subspecialist in dietotherapy Primary Health Care Center Bar Montenegro Temporary advisers and experts Rainer Aavik Deputy Mayor Pärnu City Government Estonia Anne Marie Carr Health Improvement Specialist Warrington Borough Council United Kingdom Pirous Fateh-Moghadam Head, Health Observatory Department of Health and Social Solidarity Trento Italy 11 Joan Gandy Registered Dietician and Visiting Researcher British Dietetic Association and University of Hertfordshire United Kingdom Samuel Höller Founder “A Tip:Tap” Germany Stefan Storcksdieck genannt Bonsmann Joint Research Centre European Commission Karen Watson Imperial Colleage London “Drink Up Campaign” United Kingdom Observers Irina Sergeeva Chief Specialist in the Department of Environmental Policy Department of Nature Management and Environmental Protection City of Moscow Russian Federation Irina Shiryaeva Head of Department of Environmental Policy Department of Nature Management and Environmental Protection City of Moscow Russian Federation Zhanibek Yerubayev Specialist in Division of Biostatistics and Digitalization National Center for Public Healthcare of the Ministry of Health Kazakhstan World Health Organization Regional Office for Europe João Breda Head WHO European Office for Prevention and Control of Noncommunicable Diseases Karin Geffert Consultant Water and Climate Programme WHO European Centre for Environment and Health 12 Valentina Grossi Consultant Water and Climate Programme WHO European Centre for Environment and Health Lea Samanta Nash Castro Technical Officer WHO European Office for Prevention and Control of Noncommunicable Diseases Oliver Schmoll Programme Manager Water and Climate Programme WHO European Centre for Environment and Health Kremlin Wickramasinghe Technical Officer WHO European Office for Prevention and Control of Noncommunicable Diseases WHO Country Office in the Russian Federation Elena Dmitrievna Yurasova National Professional Officer Olga Manukhina National Professional Officer Interpreters Elena Labtsova Inna Bashina 13 Annex II Meeting agenda Day 1: Thursday, 27 February 2020 08:30 Welcome refreshments and registration 09:00 Opening session Joao Breda, Oliver Schmoll and Kremlin Wickramasinghe, WHO Regional Office for Europe Round of introduction 09:30 Aims of the project: promoting tap water for health and environmental gains Oliver Schmoll and Kremlin Wickramasinghe, WHO Regional Office for Europe 09:45 Session 1: Tap water consumption in the WHO European Region Results from literature review Karin Geffert, WHO Regional Office for Europe Q&A 10:15 Healthy break 10:45 Session 2: Examples of and experiences with campaigns on tap water promotion Social marketing campaign for the promotion of water consumption: Drink Up! Karen Watson, Imperial College London Campaigns at the local level and collaboration with water providers Samuel Hol̈ler, A Tip:Tap HAPPY (Hungarian Aqua Promoting in the Young) and other ongoing programmes for the promotion of drinking-water consumption in Hungary Krisztina Tot́h, National Institute of Pharmacy and Nutrition Q&A 12:00 Lunch 13:00 Session 3: Tools and critical information for the promotion of tap-water consumption Improving health and learning through better water, sanitation and hygiene in schools Valentina Grossi, WHO Regional Office for Europe Toolkit for promotion of tap water in schools Stefan Storcksdieck genannt Bonsmann (via WebEx), European Commission, Joint Research Centre Data collection on consumption of tap water Joan Gandy (via WebEx), British Dietetic Association Q&A 14:00 Healthy break 14:30 Session 4: Regional and local experiences – ongoing and planned activities Experience with promoting tap water consumption in Pärnu Rainer Aavik, Par̈nu City Government, Estonia Perspectives on healthy weight and access to free drinking-water in Warrington Anne Marie Carr, Warrington Borough Council, United Kingdom Health behaviour surveillance system and future plans for the promotion of tap water use in the public and private sector in the Autonomous Province of Trento Pirous Fateh-Moghadam, Autonomous Province of Trento, Italy Q&A 15:30 General discussion and closing of day 1 Moderators: Oliver Schmoll and Kremlin Wickramasinghe 14 Day 2: Friday, 28 February 2021 08:45 Session 4: Regional and local experiences – ongoing and planned activities (contd.) Panel discussion on national perspectives on the promotion of tap water consumption for health and environmental gains Moderators: Oliver Schmoll and Kremlin Wickramasinghe Snezana Barjaktarovic-Labovic, Primary Health Care Center, Bar, Montenegro Rakhimzhanova Maral Tleulesovna, Committee for Quality and Safety of Goods and Services of the Ministry of Health, Kazakhstan Sadubaeva Aigerim Nabievna, Department of Public Health Protection of the Ministry of Health, Kazakhstan 09:30 Session 5: Key barriers and potential solutions for tap water promotion Introduction Lea Nash, WHO Regional Office for Europe Moderated discussion Moderator: Kremlin Wickramasinghe 11:15 Healthy break 11:45 Session 6: Next steps and commitments in pilot countries Moderators: Joao Breda and Oliver Schmoll 13:30 Farewell lunch The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. 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