Developing Public Health Policy and Capacity for Physical Activity and NCD Prevention Michael Pratt, MD, MPH Centers for Disease Control and Prevention Oxford Health Alliance, April 2009
CDC Branch and WHO Collaborating Center for Physical Activity and Health
A Few Questions Why physical activity and NCD prevention? Why middle income countries? Can we increase physical activity at the population level? Are physical activity interventions cost effective? Can public health capacity be developed to address the challenge of primary prevention of NCDs? Do multi-sectoral synergies exist?
Defining Evidence-based Public Health (Kohatsu, Fielding) The process of integrating sciencebased interventions with community preferences to improve the health of populations
Evidence-Based Public Health Practice Policy Framework Surveillance Evidence-Based Interventions Guidelines Evaluation Communication Partnerships and Networks
Physical Inactivity: A Public Health Issue Well documented health benefits High levels of inactivity globally Large burden and cost of disease Consensus recommendations Global plans from WHO for both PA and NCD prevention Extremely limited capacity and poor integration into public health practice in most countries
What do we know about the costs of inactivity? Costs due to inactivity are large and similar to those due to tobacco in all countries in which this has been assessed The proportion of medical costs due to inactivity is similar in the US, Brazil, Canada, Australia, and Europe (1-5%) Reducing inactivity is beneficial for both health and economic reasons
Recommendations Based on scientific evidence Systematic reviews Coordinated by CDC scientists Determined by independent Task Force www.thecommunityguide.org
Summary: Recommended with Strong Evidence School-based physical education Individually adapted health behavior change Social support in community settings Create or enhance access combined with outreach Community-wide campaigns
Summary: Recommended with Sufficient Evidence Point-of-decision prompts Community-scale urban design and land use Street-scale urban design and land use
Applying Evidence Based PA Recommendations in Latin America Apply Community Guide process to the Latin American PA intervention literature Implement and evaluate two community interventions in Brazil to address key gaps Build partnership network for research, public health practice and dissemination
GUIA Results Very few physical activity intervention studies in Latin America (19) Sufficient data to recommend school physical education for increasing physical activity in children in Latin America Three new community intervention types identified Possible to carry out evidence-based reviews in Latin America
New Intervention Categories Delivery of short physical activity messages Physical activity classes in community settings Community-wide policies and planning
Academia da Cidade
PROGRAMA CURITIBATIVA
MOVE CEA conclusions All of the physical activity interventions assessed are good public health investments ($14,000/QALY to $68,000/QALY) CEA provides useful information for guiding public health policy, programs and investments No recommended PA intervention strategy is clearly more cost effective than the other recommended strategies
Agita CEA Conclusions Agita Sao Paulo comprehensive community campaign is cost effective This type of intervention may be especially suitable for large urban centers in the developing world CEA of public health prevention strategies in developing countries is feasible
Why is Agita São Paulo cost effective? Highly recommended evidence-based strategy Comprehensive Creative adaptation to Brazilian context Economies of scale Low cost of delivering intervention
CEA: What do we know? Very few CEA of PA interventions have been completed, fewer still using the most widely accepted methods (Cost / QALY) Cost / QALY of PA interventions are consistently in CE range Most studies have focused on high risk or older populations or work sites Indirect cost benefits of PA are generally greater than direct medical benefits, but are even less well studied
CEA: What do we know? Community-wide PA interventions appear to be cost effective Netherlands 6000 / QALY for combined community-wide and targeted high intensity intervention at national level US $14000 to 68000 / QALY for two comprehensive community campaigns Brazil Agita São Paulo campaign Cost Saving
Building Public Health Capacity NCD policy and plans essential Adaptation of evidence-based primary prevention strategies to low/middle income countries Evaluation of promising interventions in low/middle income countries Training researchers and practitioners Re-orienting public health systems and staffing Networks and systems for sharing methods and strategies
Issues for PA Promotion in Middle Income Countries Importance of public space and security Social equity and neighborhood integrity Sustainable transport and Ciclovias Green space and environmental sustainability Utilizing the primary care clinic infrastructure Social norms for physical activity Local government coordination and innovation
Researchers Michael Pratt. Centers for Disease Control and Prevention Olga L. Sarmiento. Facultad de Medicina. Universidad de los Andes Andrea Torres. Centers for Disease Control and Prevention. PAHB. Enrique Jacoby. Pan American Health Organization Gonzalo Stierling. Red Ciclovia Ciudad de México Medellín Santiago Soacha Thomas Schmid. Centers for Disease Control and Prevention Consultant group Branka Legetic, PAHO James Hospedales, PAHO Ricardo Montezuma Fundación Ciudad Humana Brenda Perez Fundación Ciudad HumanaChihuahua Lima Pedro Nel Gonzalez/Universidad Libre, Colombia Luis Fernando Gomez FES Jose Jaime Tapias/ IDRD Guillermo Peñaloza Walk & Bike for Life Monica Davila. Ministerio de la protección Social Quito Carlos Crespo Ottawa Fiona Bull Bogotá Ciudad de Guatemala Quito Eduardo Behrentz Facultad de Ingenieria de la Universidad de los Andes Representantes de la Red de Ciclovias Unidas de las Americas y de diferentes Ciclovias de las Americas. Diseñadora Diana Fernandez Prieto Facultad de Arquitectura & Diseño. Universidad de los Andes Cuenca Research assistants Andrés Méndez. Facultad de Medicina. Universidad de los AndesEl Paso Guadalajara Laura Hernández Facultad de Medicina. San Salvador Universidad de los Andes Ana Maria Cardona Facultad de Medicina. Universidad de los Andes Andrea Gárces Facultad de Medicina. Universidad de los Andes Olivia Ferreira Facultad de Medicina. Universidad de los Andes Andrea Maldonado Facultad de Ingenieria de la Universidad de los Andes Elizabeth Zapata Universidad Nacional Jose Pacheco Facultad de Ingenieria de la Universidad de los Andes Leonardo Matiz Facultad de Ingenieria de la Universidad de los Andes Bogotá Salvador da Bahia Zapopán Zapopán Portland Caracas Guadalajara
CICLOVIA CONCLUSIONS More than 50 cities in the Americas Preliminary but limited evidence shows an association between Ciclovias and public health Trans-national studies and comparisons are needed to evaluate ciclovia s effectiveness for health. Ciclovias are a practical and efficient use of public space The scale and regularity of Ciclovia in Bogota gives it a large potential health and social impact The fast expansion and different stages of the Ciclovias provide a unique opportunity for evaluation
Brazil s Approach to Chronic Disease Prevention National policy and plan supported by legislation and funding Unit within MOH/SVS Surveillance Networked federal, state, municipal programs Physical activity as a starting point
National Policy for Health Promotion in Brazil Quality of life Physical activity Social determinants
PA Network 500+ communities funded by MOH 2005 to 2009
Key Program Elements Utilization of Primary Health Units Funding many municipalities Local government supported community PA classes Capacity building National and local surveillance data Evaluation Enhanced high quality comprehensive evaluation in select communities
What have we learned about community interventions? Community identity plays an important role in designing effective comprehensive interventions Defining success in community interventions requires understanding policy, social equity, civic engagement and other outcomes beyond health Multi-sectoral teams are required both to implement and to evaluate comprehensive community programs