Preventing chronic diseases through physical activity in the Pacific Islands. A workplace health promotion programme in Vanuatu

“It’s an emergency!” delegates declared in 2011 at the Pacific Island Forum in Fiji, convened by the Secretariat of the Pacific Community and the World Health Organization Office of the South Pacific. The emergency referred to the ever-increasing burden of non-communicable diseases (NCDs) in the Pacific Islands. The Pacific region is experiencing among the highest prevalence of NCD risk factors in the world. American Samoa, Tokelau and Nauru have overweight and obesity rates of 93.5%,7 86.2%,8 and 82.2%9 and diabetes rates are 47.3% in American Samoa, 33.6% in Tokelau, and 32.1% in Micronesia. A total of 70% of the global increase in diabetes is expected to occur in the Asia Pacific region. The Pacific Island countries and areas are predicted to experience among the greatest increases in diabetes prevalence worldwide. Urbanisation, westernisation, and rapid changes in food supply and security have contributed to obesogenic environments in the PICs. These environments support poor diets and high levels of physical inactivity. Supporting the good health of Pacific populations by encouraging and facilitating the adoption of healthier lifestyles is therefore of utmost importance. This doctoral work is the first in the specific area of physical activity health promotion in the Pacific Islands that seeks to understand and increase PA levels and reduce NCD risk. The thesis consists of nine separate but related chapters. Following the introduction in Chapter 1, a literature review in Chapter 2 provides background information on a number of research contexts, relevant for the thesis presented. The initial step was then to identify current practice in PA and healthy lifestyle promotion strategies and interventions in all 22 PICs. Therefore, Chapter 3 describes PA programmes in 20 out of 22 PICs. Eighty-four PA programmes were identified to be in existence in 2010; twenty-six of those were implemented in the workplace setting. Whilst monitoring and evaluation mechanisms are important to enhance programme effectiveness and to improve population health, findings from this study showed no evidence of monitoring and evaluation approaches in the region. As a first step to respond to the absence of evaluation work, a formative evaluation of a healthy workplace programme in Port Vila, Vanuatu, was carried out. The aim was to understand the impact of an existing programme that commenced in 2007 (Appendix L). Findings indicate that Ni-Vanuatu women are at particular risk for physical inactivity16 and as such, are at higher risk for negative health consequences. This outcome was used to tailor a specific PA intervention for these women in greater detail. Chapter 4 responds to the lack of empirical evidence on lifestyle behaviour and presents formative work carried out with Ni-Vanuatu female civil servants. The study identifies barriers and facilitators for the engagement in PA and for the adoption of healthier lifestyles in urban Ni-Vanuatu women. Findings indicate that team-based walking activities are the preferred mode of PA for the target group in Vanuatu. Further, fun-centred approaches may prove effective in increasing PA behaviour. Identified barriers include time, financial limitations, family commitments, environmental aspects and motivational hindrances. These findings were used to design a culturally-meaningful workplace PA programme that responds to local realities and needs. The workplace-based PA intervention is described in detail in Chapter 5. In summary, a team-based pedometer challenge titled Wokabaot Jalens (Walking Challenge) was designed in collaboration with Ni-Vanuatu female civil servants. The 12-week intervention was implemented with 207 participants in Port Vila, Vanuatu, in April 2011. As an important part of the intervention, local leaders were trained to a) collect accurate data and b) take ownership of the programme after the monitored phase had terminated. Baseline (N=207) and follow-up (N=133) health screenings were conducted to understand the physical effect of the intervention. Pedometers provided an objective measure of PA behaviour. Overall, pedometer-based research has predominantly focused on outcomes, with limited or no information regarding programme processes. A process evaluation was conducted in Chapter 6 to understand the effectiveness of the intervention and to provide recommendations for the adjustment and design of future programmes. A novel technique of visualising complex data is provided and a new approach in health promotion research is presented. The new thematic data visualisation (TDV) approach aids non-academics in understanding scientific data in a simple way. This may engage local health practitioners and potential donor agencies to support and initiate future action. Evaluation findings indicate that likert-scale questions have little value in PICs which is assumed to be due to a cultural inclination to assent with external ideas. Open-ended questions, however, revealed more information. Thematic findings indicate that positive health outcomes are the most desired programme effect; that unmotivated team members were considered as counterproductive; that an expansion of the programme to the wider community was the dominant suggestion for programme improvement; and that motivational issues were the biggest challenge for programme participation. Previous research (Australia, USA) indicates that walking interventions can be effective, at least in the short term, to increase PA levels in women. However, no research has been undertaken to understand whether this strategy is effective in Pacific women. The efficacy of the Wokabaot Jalens was therefore assessed in Chapter 7. Qualitative and quantitative probabilities were calculated to assess the magnitude of inference. Conclusions are based on inferential statistics that emphasise precision of estimation rather than null hypothesis testing (P values). Overall, a positive effect was identified for PA behaviour which increased by 26.1% (2,513 ± 6,922). High risk individuals benefitted most from the intervention: a large positive effect was identified for PA behaviour (large, +229%). Positive effects were also found for waist circumference (moderate, -6.2%) serum glucose (small, -15.9%) and triglycerides (moderate, -31.%). Chapter 8 provides an ethnographic investigation that describes the challenges and successes of managing health promotion programmes experienced by the researcher in different PICs (Vanuatu, Tuvalu, Tonga, Kiribati), taking cultural values into consideration. In particular, programme logistics, on-site issues, opportunities and challenges for health promotion programme sustainability, limitations and success stories are reported. The previously designed intervention from Vanuatu serves as an example to describe hands-on experience. Context specific issues that were observed during Pacific health promotion initiatives were categorised into thematic findings and classified as individual, cultural and external barriers and facilitators. Whilst individual issues (attitude, perception, acceptance, distribution) were largely identified as facilitators for health promotion action, cultural (structures, communication, language, gender, dress code, data precision) and environmental issues (climate, funding, conduct, geographical remoteness) may challenge health promotion efforts. The presentation of this reflective praxis is intended to aid future practitioners and researchers in programme design, management and evaluation and seeks to enhance collaboration with local personnel and authorities. Finally, Chapter 9 describes the intricacies of external factors responsible for the Pacific health crisis. These include genetic susceptibilities, globalisation and contemporary environments, a heavy dependence on external aid, a limited Pacific health workforce, underfunded political systems, and last but not least individual lifestyle behaviours and choices. The chapter concludes that only culturally-centred health promotion approaches which take the attitude and belief system into account are realistic to result in Pacific health progress. In summary, this doctoral work provides the first robust approach of evidence-based solutions for PA health promotion efforts in the Pacific region. This work is valuable in the context of the absence of evidence around programme efficacy, and other formative and process evaluation seen as best practice in health promotion. Yet it is hard to see an optimistic future in controlling the spread of NCDs in the region because of the complexities involved. If a medical emergency is defined as a large amount of human suffering and preventable premature death, then yes, the PICs are in a state of medical emergency. The current state will likely remain until profound social and economic changes are set into process

Associations Between Social Capital and Depressive Symptoms Among College Students in 12 Countries: Results of a Cross-National Study

Backhaus I, Ramirez Varela A, Khoo S, et al. Associations Between Social Capital and Depressive Symptoms Among College Students in 12 Countries: Results of a Cross-National Study. Frontiers in Psychology. 2020;11: 644.Introduction: A mental health crisis has hit university campuses across the world. This study sought to determine the prevalence and social determinants of depressive symptoms among university students in twelve countries. Particular focus was placed on the association between social capital and depressive symptoms. Methods: A cross-sectional study was conducted among students at their first year at university in Europe, Asia, the Western Pacific, and Latin and North America. Data were obtained through a self-administered questionnaire, including questions on sociodemographic characteristics, depressive symptoms, and social capital. The simplified Beck’s Depression Inventory was used to measure the severity of depressive symptoms. Social capital was assessed using items drawn from the World Bank Integrated Questionnaire to Measure Social Capital. Multilevel analyses were conducted to determine the relationship between social capital and depressive symptoms, adjusting for individual covariates (e.g., perceived stress) and country-level characteristics (e.g., economic development). Results: Among 4228 students, 48% presented clinically relevant depressive symptoms. Lower levels of cognitive (OR: 1.82, 95% CI: 1.44–2.29) and behavioral social capital (OR: 1.51, 95% CI: 1.29–1.76) were significantly associated with depressive symptoms. The likelihood of having depressive symptoms was also significantly higher among those living in regions with lower levels of social capital. Conclusion: The study demonstrates that lower levels of individual and macro-level social capital contribute to clinically relevant depressive symptoms among university students. Increasing social capital may mitigate depressive symptoms in college students

Worldwide use of the first set of physical activity Country Cards: The Global Observatory for Physical Activity - GoPA!

Background: The work of The Global Observatory for Physical Activity-GoPA! is the first global effort to compile standardized country-level surveillance, policy and research data for physical activity in order to better understand how countries and regions address promoting physical activity. GoPA! developed standardized country-specific physical activity profiles (“Country Cards”) to summarize country-level data through 2013. The aim of this study was to assess use of the Country Cards, identify the factors associated with their use, and develop recommendations for supporting country-level physical activity promotion. Methods: Cross sectional internet-based survey conducted between August–October 2016. Target study participants were national physical activity leaders and advocates in academia, government and practice from the GoPA! countries, and members of the International Society of Physical Activity and Health. A Country Card use composite score was created based on the diversity and frequency of use. Statistical analyses on the associations between the composite score and respondent characteristics, country characteristics, barriers and opinions were conducted (including descriptive analyses and a logistic regression with robust standard errors). Results: One hundred forty three participants from 68 countries completed the survey. Use of the Country Cards was associated with being part of the GoPA! network, knowing about the Country Cards, and on the stage of country capacity for physical activity promotion. Country Card knowledge varied by country income group, region and the country specific context. More diverse and frequent use of the cards (highest tertile of the composite score for use) was associated with: 1. Being a country contact vs general participant (OR 18.32–95% CI 5.63–59.55, p = 0.002), and 2. Collaborating with a government representative working in NCDs on a monthly or more frequent contact vs less frequent contact (OR 3.39–95% CI 1.00–11.54, P < 0.05). Conclusions: For the Country Cards to have a broader impact, GoPA! will need to widen its reach beyond the academic sector. With further refinement of the cards, and training in their implementation, they could be an important tool for advancing country capacity for contextually-relevant strategies, actions and timelines for PA promotion

Status and trends of physical activity surveillance, policy, and research in 164 countries: Findings from the Global Observatory for Physical Activity—GoPA! 2015 and 2020 Surveys

BACKGROUND: Physical activity (PA) surveillance, policy, and research efforts need to be periodically appraised to gain insight into national and global capacities for PA promotion. The aim of this paper was to assess the status and trends in PA surveillance, policy, and research in 164 countries. METHODS: We used data from the Global Observatory for Physical Activity (GoPA!) 2015 and 2020 surveys. Comprehensive searches were performed for each country to determine the level of development of their PA surveillance, policy, and research, and the findings were verified by the GoPA! Country Contacts. Trends were analyzed based on the data available for both survey years. RESULTS: The global 5-year progress in all 3 indicators was modest, with most countries either improving or staying at the same level. PA surveillance, policy, and research improved or remained at a high level in 48.1%, 40.6%, and 42.1% of the countries, respectively. PA surveillance, policy, and research scores decreased or remained at a low level in 8.3%, 15.8%, and 28.6% of the countries, respectively. The highest capacity for PA promotion was found in Europe, the lowest in Africa and low- and lower-middle-income countries. Although a large percentage of the world's population benefit from at least some PA policy, surveillance, and research efforts in their countries, 49.6 million people are without PA surveillance, 629.4 million people are without PA policy, and 108.7 million live in countries without any PA research output. A total of 6.3 billion people or 88.2% of the world's population live in countries where PA promotion capacity should be significantly improved. CONCLUSION: Despite PA is essential for health, there are large inequalities between countries and world regions in their capacity to promote PA. Coordinated efforts are needed to reduce the inequalities and improve the global capacity for PA promotion

The Toronto Charter for Physical Activity (Die Toronto-Charta fur Bewegung)

The World Health Organization and other international health promotion organisations and agencies have recognised physical inactivity as a major health risk factor. However, physical inactivity still receives less attention than other risk factors for non-communicable diseases (e.g. tobacco use, unhealthy diets and overweight). Therefore, in 2009 the Council for Global Advocacy for Physical Activity (GAPA) of the International Society for Physical Activity and Health (ISPAH) initiated the development of the first Charter for Physical Activity as a global call for action. The Charter was presented at the International Congress on Physical Activity and Public Health in Toronto, Canada, in May 2010. A strategic implementation of the Charter fosters intersectoral collaboration and can significantly contribute to increasing the prevalence of a population-wide active lifestyle

Science has no borders, so should scientific publishing: a position statement from the <i>Journal of Physical Activity and Health</i>

ISSN:1543-3080ISSN:1543-547

Status and Trends of Physical Activity Surveillance, Policy, and Research in 164 Countries: Findings From the Global Observatory for Physical Activity—GoPA! 2015 and 2020 Surveys

Background: Physical activity (PA) surveillance, policy, and research efforts need to be periodically appraised to gain insight into national and global capacities for PA promotion. The aim of this paper was to assess the status and trends in PA surveillance, policy, and research in 164 countries. Methods: We used data from the Global Observatory for Physical Activity (GoPA!) 2015 and 2020 surveys. Comprehensive searches were performed for each country to determine the level of development of their PA surveillance, policy, and research, and the findings were verified by the GoPA! Country Contacts. Trends were analyzed based on the data available for both survey years. Results: The global 5-year progress in all 3 indicators was modest, with most countries either improving or staying at the same level. PA surveillance, policy, and research improved or remained at a high level in 48.1%, 40.6%, and 42.1% of the countries, respectively. PA surveillance, policy, and research scores decreased or remained at a low level in 8.3%, 15.8%, and 28.6% of the countries, respectively. The highest capacity for PA promotion was found in Europe, the lowest in Africa and low- and lower-middle-income countries. Although a large percentage of the world’s population benefit from at least some PA policy, surveillance, and research efforts in their countries, 49.6 million people are without PA surveillance, 629.4 million people are without PA policy, and 108.7 million live in countries without any PA research output. A total of 6.3 billion people or 88.2% of the world’s population live in countries where PA promotion capacity should be significantly improved. Conclusion: Despite PA is essential for health, there are large inequalities between countries and world regions in their capacity to promote PA. Coordinated efforts are needed to reduce the inequalities and improve the global capacity for PA promotion

Status and Trends of Physical Activity Surveillance, Policy, and Research in 164 Countries: Findings From the Global Observatory for Physical Activity—GoPA! 2015 and 2020 Surveys

Background: Physical activity (PA) surveillance, policy, and research efforts need to be periodically appraised to gain insight into national and global capacities for PA promotion. The aim of this paper was to assess the status and trends in PA surveillance, policy, and research in 164 countries. Methods: We used data from the Global Observatory for Physical Activity (GoPA!) 2015 and 2020 surveys. Comprehensive searches were performed for each country to determine the level of development of their PA surveillance, policy, and research, and the findings were verified by the GoPA! Country Contacts. Trends were analyzed based on the data available for both survey years. Results: The global 5-year progress in all 3 indicators was modest, with most countries either improving or staying at the same level. PA surveillance, policy, and research improved or remained at a high level in 48.1%, 40.6%, and 42.1% of the countries, respectively. PA surveillance, policy, and research scores decreased or remained at a low level in 8.3%, 15.8%, and 28.6% of the countries, respectively. The highest capacity for PA promotion was found in Europe, the lowest in Africa and low- and lower-middle-income countries. Although a large percentage of the world’s population benefit from at least some PA policy, surveillance, and research efforts in their countries, 49.6 million people are without PA surveillance, 629.4 million people are without PA policy, and 108.7 million live in countries without any PA research output. A total of 6.3 billion people or 88.2% of the world’s population live in countries where PA promotion capacity should be significantly improved. Conclusion: Despite PA is essential for health, there are large inequalities between countries and world regions in their capacity to promote PA. Coordinated efforts are needed to reduce the inequalities and improve the global capacity for PA promotion.</jats:p