Limits and potentialities of educating family health workers for physical activity promotion: a participatory research

O progresso do Sistema Único de Saúde brasileiro nas últimas décadas, principalmente com a implementação da Estratégia de Saúde da Família, resultou em melhorias no atendimento à população e no fortalecimento de ações para promover a atividade física, incluindo a incorporação do profissional de Educação Física nos cuidados básicos de saúde. No entanto, existem desafios a serem superados, tais como o desenvolvimento da educação dos trabalhadores da área da saúde de acordo com os princípios orientadores do Sistema Único de Saúde. Desta forma, o objetivo desse estudo foi avaliar os limites e as potencialidades da educação para a promoção da atividade física na Estratégia Saúde da Família por meio de uma pesquisa participativa baseada na comunidade, através da construção de um programa educativo com as equipes de saúde. As análises da conversação e da fala foram aplicadas aos dados de três grupos focais (dois no início e um após o programa) e a triangulação foi usada para combinar esses dados com os dados de notas de campo e notas reflexivas escritas pelo pesquisador e também por um observador independente. Cinco limites e potencialidades foram identificados para a educação da promoção da atividade física: organização do trabalho e educação no trabalho; relação do profissional com a atividade física; ponto de vista profissional sobre o processo saúde-doença, no que se refere ao aconselhamento sobre atividade física; falta de cuidados para o profissional de saúde e o aprendizado incidental; e a avaliação dos elementos-chave da estratégia pedagógica. Os resultados apontam para a necessidade de melhorar a organização do trabalho e a saúde oferecida aos próprios profissionais, de fortalecer ações de educação para valorizar a educação permanente e interprofissional e de trabalhar a conscientização dos profissionais sobre a prática e promoção da atividade física.Progress in the last decades in the Brazilian Unified Health System, mainly with the implementation of the Family Health Strategy, has resulted in improvements in care to the population and in strengthening of actions to promote physical activity, including the incorporation of Physical Education professional in basic healthcare. Nevertheless, there are challenges to overcome, such as the development of health workers’ education in accordance with the Unified Health System guiding principles. Therefore, the objective of the current study was to evaluate limits and potentialities of educating for the promotion of physical activity in the Family Health Strategy through a community-based participatory research, by constructing an education program with the health teams. The analysis of conversation and speech was applied to the data from three focus groups (two at the beginning and one after the program) and triangulation was used to combine this data with that from field notes and reflective notes written by the researcher and also by an independent observer. Five limits and potentialities were identified for physical activity promotion education: work organization and on-the-job education; the relation of the worker with physical activity; the worker point-of-view about the health-disease process and in regard to counseling about physical activity; lack of care to the health worker and the incidental learning; and the appraisal of key-elements of pedagogical strategy. Findings point to a necessity to improve the work organization and the healthcare offered to the worker themselves, to strengthen education actions to value permanent and inter-professional education and to work the conscience of the workers about practice and promotion of physical activity

Expanding health taxation to other unhealthy behaviours and harmful activities

The use of taxation to improve public health has been successful in tackling tobacco and alcohol, with positive and direct effect on health outcomes. However, the taxation of other unhealthy behaviours and activities negatively affecting health (e.g. the increased use of cars) has not yet been explored for the promotion of public health and societal well-being, in particular for reducing premature mortality from non-communicable diseases (NCDs), which account for 70% of global deaths. Taxation can be expanded to unhealthy behaviours and activities affecting individuals’ health and wellbeing, in the pursuit of public health goals. For unhealthy behaviours and some other activities, taxation might be defined at local levels of government, as a way to tackle local health problems. Local governments should be actively collaborating with other levels of government (e.g. federal level), to identify taxation-based solutions for health problems that directly affect their jurisdiction. We use the examples of air pollution, land use, gambling and farming practices to illustrate the challenges facing local authorities, and opportunities to deal with them through taxation and health promotion, particularly in tackling NCDs

The impact of transport, housing, and urban development interventions on older adults' mobility: a systematic review of experimental and quasi-experimental studies

Background: Age-friendly cities and communities aim to enhance and preserve the functional abilities of older adults. This systematic review assesses the impact of interventions in transportation, housing, and urban development on the mobility of older adults. Methods: We systematically searched MEDLINE, Embase, CINAHL, Scopus, PsycINFO, and SocINDEX up to July 2022 to identify studies that evaluated the impact of transportation, housing, and urban development interventions on older adults' mobility. Only randomised controlled trials and quasi-experimental studies with control groups were included to establish a causal relationship between interventions and mobility outcomes. Findings: We included a total of 15 studies, of which six were randomised controlled trials. Included studies were conducted in high-income settings and employed diverse metrics to assess mobility outcomes. Among housing interventions, three studies examined the impact of assistive technology within home environments for frail older adults. Two of these interventions maintained functional status without improvement, while the third showed a significant decline in outcomes, with the control group faring even worse. Public transport interventions, focused on enhancing mobility through educational initiatives and policy revisions, consistently produced positive outcomes. Interventions related to driving training for older adults, including in-class and on-road assessments, demonstrated beneficial effects. Results from studies evaluating urban design interventions were more varied, with some enhancing mobility by making public spaces more accessible for older adults and others yielding mixed results following infrastructure changes. Interpretation: Interventions in the built environments of older adults, specifically targeting transportation, housing and urban development, have the potential to enhance mobility and related outcomes according to rigorously designed quantitative evaluations. Due to heterogeneity in how mobility is conceptualised in the literature, greater harmonisation in measurement of mobility would help us understand how the social and built environment contribute to maintaining and improving mobility in older adults. Funding: World Health Organization

Can air pollution negate the health benefits of cycling and walking?

Active travel (cycling, walking) is beneficial for the health due to increased physical activity (PA). However, active travel may increase the intake of air pollution, leading to negative health consequences. We examined the risk-benefit balance between active travel related PA and exposure to air pollution across a range of air pollution and PA scenarios. The health effects of active travel and air pollution were estimated through changes in all-cause mortality for different levels of active travel and air pollution. Air pollution exposure was estimated through changes in background concentrations of fine particulate matter (PM2.5), ranging from 5 to 200μg/m3. For active travel exposure, we estimated cycling and walking from 0 up to 16h per day, respectively. These refer to long-term average levels of active travel and PM2.5 exposure. For the global average urban background PM2.5 concentration (22μg/m3) benefits of PA by far outweigh risks from air pollution even under the most extreme levels of active travel. In areas with PM2.5 concentrations of 100μg/m3, harms would exceed benefits after 1h 30min of cycling per day or more than 10h of walking per day. If the counterfactual was driving, rather than staying at home, the benefits of PA would exceed harms from air pollution up to 3h 30min of cycling per day. The results were sensitive to dose-response function (DRF) assumptions for PM2.5 and PA. PA benefits of active travel outweighed the harm caused by air pollution in all but the most extreme air pollution concentrations.MT and JW: The work was undertaken by the Centre for Diet and Activity Research (CEDAR), a UKCRC Public Health Research Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, and the Wellcome Trust, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged. AJN, DRR, MJN, SK and TG: The work was supported by the project Physical Activity through Sustainable Transportation Approaches (PASTA) funded by the European Union's Seventh Framework Program under EC‐GA No. 602624-2 (FP7-HEALTH-2013-INNOVATION-1). The sponsors had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. JW is supported by MRC Population Health Scientist fellowship. THS is supported by the Brazilian Science without Borders Scheme (Process number: 200358/2014-6) and the Sao Paulo Research Foundation (Process number: 2012/08565-4).This is the final version of the article. It first appeared from Elsevier via http://dx.doi.org/10.1016/j.ypmed.2016.02.00

Validation of the scale for evaluation of environment perception for physical activity practice in adults living in region of low socioeconomic level

O objetivo do estudo foi verificar a validade de uma escala de percepção do ambiente para a prática de atividade física em adultos. Este estudo de validação teve duas amostras: 1) Comparação da escala com dados avaliados de forma objetiva e com a prática de atividade física (767 indivíduos com 18 anos ou mais); 2) Estudo de reprodutibilidade (30 indivíduos com 60 anos ou mais). Ambas as amostras residiam no Distrito de Ermelino Matarazzo, zona leste de São Paulo, SP. A escala de percepção do ambiente para a prática de atividade física foi composta por questões embasadas na escala NEWS e numa escala de apoio social para a prática de atividade física e a versão final foi composta de 38 questões. Análises de dados: a escala foi comparada com o ambiente avaliado de forma objetiva, com o nível de atividade física e por meio de medida repetida. Os coeficientes de correlação para as questões variaram de r=0,51 a até r=0,89 e para os escores de r=0,72 a até r=0,94. Houve diferença estatisticamente significativa na média do escore de percepção de facilidades/conveniências para a prática de atividade física segundo a classificação do ambiente avaliado de forma objetiva (p<0,01). As pessoas que praticavam alguma atividade física no tempo de lazer tiveram maiores médias nos escores de facilidades/conveniências (p<0,01), percepção de segurança geral (p=0,033) e de apoio social (p=0,001). A escala apresentou resultados satisfatórios de reprodutibilidade para a amostra de idosos e de validade para os adultos, principalmente, na percepção de facilidades/conveniências

Sedentary behaviour and risk of all-cause, cardiovascular and cancer mortality, and incident type 2 diabetes: a systematic review and dose response meta-analysis.

PURPOSE:  To estimate the strength and shape of the dose-response relationship between sedentary behaviour and all-cause, cardiovascular disease (CVD) and cancer mortality, and incident type 2 diabetes (T2D), adjusted for physical activity (PA). Data Sources: Pubmed, Web of Knowledge, Medline, Embase, Cochrane Library and Google Scholar (through September-2016); reference lists. Study Selection: Prospective studies reporting associations between total daily sedentary time or TV viewing time, and ≥ one outcome of interest. Data Extraction: Two independent reviewers extracted data, study quality was assessed; corresponding authors were approached where needed. Data Synthesis: Thirty-four studies (1,331,468 unique participants; good study quality) covering 8 exposure-outcome combinations were included. For total sedentary behaviour, the PA-adjusted relationship was non-linear for all-cause mortality (RR per 1 h/day: were 1.01 (1.00-1.01) ≤ 8 h/day; 1.04 (1.03-1.05) > 8 h/day of exposure), and for CVD mortality (1.01 (0.99-1.02) ≤ 6 h/day; 1.04 (1.03-1.04) > 6 h/day). The association was linear (1.01 (1.00-1.01)) with T2D and non-significant with cancer mortality. Stronger PA-adjusted associations were found for TV viewing (h/day); non-linear for all-cause mortality (1.03 (1.01-1.04) ≤ 3.5 h/day; 1.06 (1.05-1.08) > 3.5 h/day) and for CVD mortality (1.02 (0.99-1.04) ≤ 4 h/day; 1.08 (1.05-1.12) > 4 h/day). Associations with cancer mortality (1.03 (1.02-1.04)) and T2D were linear (1.09 (1.07-1.12)). CONCLUSIONS:  Independent of PA, total sitting and TV viewing time are associated with greater risk for several major chronic disease outcomes. For all-cause and CVD mortality, a threshold of 6-8 h/day of total sitting and 3-4 h/day of TV viewing was identified, above which the risk is increased

How are we going? Study of active commuting in Brazil.

Introdução: O deslocamento ativo tem estreita relação com problemas de saúde pública da atualidade e sua promoção pode contribuir para melhorias quanto à mobilidade urbana, estado de saúde e proteção do meio ambiente. Entretanto, a maior parte das pesquisas sobre o tema tem sido desenvolvida em países de renda alta. A presente tese busca ampliar a investigação sobre o deslocamento ativo no Brasil. Objetivos: i) Descrever a frequência, a distribuição e a variação temporal de indicadores do deslocamento ativo em populações brasileiras; ii) Avaliar o impacto de mudanças no padrão de transporte da população sobre o deslocamento ativo, o tempo sedentário e desfechos de saúde em populações brasileiras. Métodos: Tese composta por sete manuscritos. O primeiro apresenta revisão sistemática de estudos com informações sobre a prática de deslocamento ativo na América Latina e Caribe; o segundo descreve estimativas representativas da população brasileira sobre a prática de deslocamento ativo para o trabalho; o terceiro e o quarto descrevem a frequência e tendência temporal do deslocamento ativo na Região Metropolitana de São Paulo (ciclistas e escolares); o quinto discute a questão da mobilidade urbana e do direito à cidade em São Paulo; o sexto e o sétimo avaliam o impacto de mudanças no padrão de mobilidade da metrópole paulistana sobre a prática de deslocamento ativo, tempo não-ativo de deslocamento e tempo total de deslocamento, bem como sobre a poluição do ar e saúde da população. Resultados: A prevalência mediana de deslocamento ativo encontrada em diferentes locais do Brasil foi de 12 por cento , variando entre 5,1 por cento em Palmas (Tocantins) a 58,9 por cento em Rio Claro (São Paulo) (Manuscrito 1). Um terço dos homens e das mulheres desloca-se a pé ou de bicicleta de casa para o trabalho no país. Em ambos os sexos, esta proporção diminui com o aumento da renda e da escolaridade e é maior entre os mais jovens, entre os que residem em áreas rurais, e na região Nordeste. Em todas as regiões metropolitanas estudadas, o quinto das pessoas de menor renda apresenta uma maior frequência de deslocamento ativo (Manuscrito 2). Entre os anos de 2007 e 2012, observamos redução no número de ciclistas em São Paulo e diferenças expressivas na proporção de ciclistas entre homens e mulheres (9,7 por mil habitantes versus 1,4 por mil habitantes em 2012) (Manuscrito 3). Também verificamos uma queda na proporção de crianças que se deslocam ativamente para a escola entre os anos de 1997 e 2012 (Manuscrito 4). O cenário epidemiológico do deslocamento ativo no país é resultante da disputa pelo direito à cidade, com repercussões na transição de mobilidade humana e na saúde e qualidade de vida da população, como podemos observar no caso de São Paulo (Manuscrito 5). A construção de uma São Paulo mais inclusiva, com menores distâncias para os deslocamentos cotidianos e maior frequência de caminhada e bicicleta, levaria à substancial redução do tempo total e do tempo sedentário despendidos nos deslocamentos, sem diminuir a duração do deslocamento ativo (Manuscrito 6). Traria também ganhos à saúde da população, sobretudo pelo aumento da prática de atividade física e da redução da poluição do ar (Manuscrito 7). Conclusões: A prática de deslocamento ativo no Brasil apresenta marcadas diferenças segundo região e características sociodemográficas. De um modo geral, esta prática vem diminuindo no país, o que deve contribuir negativamente para a saúde da população. A promoção de cidades mais inclusivas e compactas, com o favorecimento a modos ativos de deslocamento, pode contribuir para reverter esta preocupante tendência.Introduction: Active commuting is closely related to current public health issues and its promotion can contribute to improvements in urban mobility, health and environmental protection. However, research on the subject is largely concentrated in high-income countries. This thesis aims to expand research on active commuting in Brazil. Objectives: i) To describe the frequency, distribution and time trend of active commuting indicators in Brazilian populations; ii) To assess the impact of travel pattern changes on active commuting, sedentary time and health outcomes in Brazilian populations. Methods: The thesis consists of seven manuscripts. The first manuscript is a systematic review of studies with information on active commuting practice in Latin America and the Caribbean; the second describes nationally representative estimates about active commuting to work in Brazil; the third and fourth describe active commuting frequency and time trends in São Paulo metropolitan area (cyclists and schoolchildren); the fifth discusses the issue of urban mobility and the right to the city of São Paulo; the sixth and seventh assess the impact of changes in São Paulo travel pattern on active commuting, non-active commuting and total travel time as well on air pollution and population health. Results: The median prevalence of active commuting found in Brazilian settings was 12 per cent , ranging from 5.1 per cent in Palmas (Tocantins) to 58.9 per cent in Rio Claro (Sao Paulo) (Manuscript 1). One-third of men and women walk or cycle for commuting to work in Brazil. In both sexes, this proportion decreases with increasing income and education and is higher among younger people, those living in rural areas, and in the Northeast. In all Brazilian metropolitan areas studies, people in the lowest quintile of income had a higher frequency of active commuting (Manuscript 2). Between 2007 and 2012, we observed a decreasing number of cyclists in São Paulo and marked sex differences in the proportion of cyclists (9.7 per thousand inhabitants for men versus 1.4 per thousand inhabitants for women in 2012) (Manuscript 3). We also found a decrease in the proportion of children who are actively commuting to school between 1997 and 2012 (Manuscript 4). The epidemiological scenario of active commuting in Brazil is the result of a historical dispute for the right to the city, with repercussions for human mobility transition and people\'s health and quality of life, as can be seen in the case of São Paulo (Manuscript 5). Building a more inclusive São Paulo, with shorter distances and more walking and cycling, would lead to substantial reductions of total and sedentary commuting time, without reducing active commuting time (Manuscript 6). It would also result in improvements for peoples health, particularly due to the increasing physical activity and decreasing air pollution (Manuscript 7). Conclusions: Active commuting in Brazil shows marked regional and socioeconomic contrasts. Overall, this practice has decreased, which should contribute negatively to the health of Brazilians. The promotion of more inclusive and compact cities, favoring active travel, can help reverse this worrying trend

Construction and evaluation of an education program for the promotion of physical activity together with family health teams

INTRODUÇÃO: Promover a atividade física na atenção básica passa por mudar sua representação social, de técnica curativa e reparadora, junto aos profissionais de saúde. Isto se dará, dentre outras ações, pela educação transformadora do ser, a partir da problematização do mundo em que vive, em consonância com a proposta da Política Nacional de Educação Permanente, que rege as ações de formação em saúde na Estratégia de Saúde da Família. OBJETIVO: Construir e avaliar um programa educativo com os profissionais das equipes de saúde da família para a promoção de atividade física. MÉTODOS: Trata-se de um estudo de intervenção com grupo controle, com trabalhadores de saúde de duas Unidades Básicas de Saúde de Ermelino Matarazzo, Município de São Paulo. O programa educativo foi composto de seis encontros de uma hora e meia de duração, entre julho e outubro de 2010. Os referenciais teóricos da construção do programa foram a Teoria Educacional de Paulo Freire e a Educação Permanente. Para o processo de investigação temática, foram realizados dois grupos focais ao início do estudo e para a avaliação do efeito do programa educativo sobre o significado da prática de atividade física e aconselhamento sobre atividade física, realizou-se um grupo focal com os participantes ao final do programa. Além disso, todos os encontros foram registrados pelo professor e por um observador independente. Todo o material qualitativo foi analisado segundo o método de análise da conversação e da fala. O efeito do programa sobre comportamentos de saúde relacionados à atividade física foi avaliado a partir da comparação dos grupos segundo a média das diferenças dos valores antes e depois da intervenção para as variáveis de atividade física no tempo livre e de deslocamento, o uso de televisão e de computador, e a soma de barreiras para a prática de atividade física no tempo livre, a partir do teste U de Mann-Whitney. Adotou-se como nível de significância o valor de p < 0,05 para todas as análises. RESULTADOS: O programa educativo para a promoção de atividade física teve ótima aceitação entre os ACS e auxiliares de enfermagem, tendo sido observadas alterações positivas sobre o significado da prática de atividade física e nova percepção sobre o aconselhamento feito pelos profissionais. Foram observados importantes limitantes institucionais à promoção de atividade física. CONCLUSÃO: O programa educativo promoveu alterações positivas no significado da prática de atividade física e na qualidade do aconselhamento junto aos profissionais de saúde, sendo também reconhecido por estes como espaço de diálogo e acolhimento. Entretanto, para que as potencialidades do programa sejam plenamente aproveitadas, é imprescindível superar limitantes institucionais à promoção de atividade física e de aprendizagem em serviçoINTRODUCTION: Promoting physical activity in primary care must consider changing its social representation of a curative and restorative technique from health professionals. This will occur, among other actions, by the transforming education, from questioning the world we live, according to the National Policy of Permanent Education, which guides the educational actions of the Health Family Strategy. OBJECTIVE: To construct and evaluate an education program for the promotion of physical activity together with family health teams. METHODS: We conducted a controlled intervention with workers from two primary healthcare units in Ermelino Matarazzo, municipality of Sao Paulo. The education program consisted of six meetings of one hour and a half each (nine hours total), between July and October of 2010. The theoretical frameworks for its construction were the Educational Theory of Paulo Freire and the Permanent Education. Two focus groups were held at the beginning of the program to investigate the minimum thematic universe and another focus group was held at the end to evaluate the effect of the education program on the meaning of the practice and counseling about physical activity. Also, all meetings were reported by the professor and by an independent observer. Qualitative data were analyzed using the speech and conversation analysis method. The programs effects on health behaviors related to physical activity were evaluated by comparing both groups according to free time physical activity, active commuting, use of television and computer, and the sum of barriers reported for free time physical activity practice. Mann-Whitney was used and significance level of p < 0,05 was adopted for all analysis. RESULTS: The education program for physical activity promotion had great acceptation among lay health workers and assistant nurses. Positive changes were observed in the meaning of the practice and counseling about physical activity. We also identified important institutional obstacles for physical activity promotion. CONCLUSION: The education program for physical activity promotion led to positive changes over the meaning of the practice and counseling about physical activity among health professionals, being also recognized by them as a space for dialogue and care. However, if we want to fully use all the programs potentialities, it is indispensable to overcome institutional limits for physical activity promotion and health educatio