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?
Defining Evidence-based Public
Health (Kohatsu, Fielding)
• The process of integrating
science-based interventions with community
preferences to improve the health of
populations
Evidence-Based Public Health Practice
• Policy Framework
• Surveillance
• Evidence-Based Interventions
• Guidelines
• Evaluation
• Communication
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
Recommendations
Based on scientific evidence
Systematic reviews
Coordinated by CDC scientists
Determined by independent Task Force
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
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
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
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
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
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
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
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
Chihuahua Portland Zapopán Cuenca Quito El Paso Quito
Ciudad de México Medellín Soacha
Guadalajara Zapopán Santiago Caracas Bogotá San Salvador Ciudad de Guatemala Salvador da Bahia Ottawa Lima Bogotá Guadalajara 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
• 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 Humana
• 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
• Carlos Crespo
• Fiona Bull
• 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 Research assistants
• Andrés Méndez. Facultad de Medicina. Universidad de los Andes
• Laura Hernández Facultad de Medicina. 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
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
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
9
Quality of life
9
Physical activity
9
Social determinants
National Policy for Health
Promotion in Brazil
PA Network 500+
communities funded by MOH
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
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
