Abstracts

Introduction

Physical inactivity is a global pandemic ¹1 . Kohl HW, Craig CL, Lambert EV, Inoue S, Alkandari JRA, Leetongin G, et al. The pandemic of physical inactivity: global action for public health. Lancet 2012; 380:295-305., responsible for 9% of premature mortality worldwide in 2008 ²2 . Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012; 380:219-29.. In order to reduce the high proportion of inactive individuals around the world ³3 . Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet 2012; 380:247-57., the implementation of incentive programs as well as mobilization and support for physical activity programs have been considered priority strategies to promote health in many countries ⁴4 . Pratt M, Sarmiento OL, Montes F, Oglvie D, Bess H, Marcus H, et al. The implications of megatrends in information and communication technology and transportation for changes in global physical activity. Lancet 2012; 380:282-93.^,55 . Cleland CL, Tully MA, Kee F, Cupples ME. The effectiveness of physical activity interventions in socio-economically disadvantaged communities: a systematic review. Prev Med 2012; 54:371-80.^,66 . Heath GW, Parra DC, Sarmiento OL. Evidence-based physical activity interventions: lessons from around the world. Lancet 2012; 380:272-81.. Specifically in low and middle-income countries, the emphasis of public health policies has been on groups who have less access to physical activity opportunities ⁷7 . Knuth AG, Malta DC, Cruz DK, Freitas PC, Lopes MP, Fagundes J, et al. Rede nacional de atividade física do Ministério da Saúde: resultados e estratégias avaliativas. Rev Bras Ativ Fís Saúde 2010; 15:229-34.^,88 . Malta DC, da Silva JB. Policies to promote physical activity in Brazil. Lancet 2012; 380:195-6.. However, there is still ample room for improvement regarding the central role that public policy can play in the promotion and facilitation of healthy lifestyles, particularly in low and middle-income countries ⁹9 . Lachat C, Otchere S, Roberfroid D, Abubakari A, Seret FMA, Mileszevic J, et al. Diet and physical activity for the prevention of noncommunicable diseases in low-and middle-income countries: a systematic policy review. PLoS Med 2013; 10:e1001465..

Brazil has a Unified National Health System (SUS) that uses primary health care settings as the first step for prevention and treatment. Primary care clinics are one of the potential entry points to deliver physical activity counseling and referral to programs linked to the corresponding health care model in Brazil. One of the pillars of this model is the Family Health Strategy (FHS), which covers 47.7% of registered households in Brazil, with a higher proportion in the Northeast of the country ¹⁰10 . Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios. Um panorama da saúde no Brasil: acesso e utilização de serviços, condições de saúde e fatores de risco e proteção à saúde, 2008. Brasília: Instituto Brasileiro de Geografia e Estatística; 2008.. Family Health Teams (FHT), composed of a general physician, nurse and community health agents, have responsibilities in a delimited territory encompassing around 800 to 1,000 families to provide health promotion, prevention and rehabilitation actions, and resolve some of the most frequent health problems that affect the community. To support and improve the actions of the FHTs, the Multidisciplinary Primary Care Teams [Núcleo de Apoio à Saúde da Família – NASF] was created to share health practices and specific knowledge in diverse areas with the FHTs. The NASF is composed of different health professionals including nutritionists, physical educators, physiotherapists, psychologists, speech therapists, occupational therapists, psychiatrists, and social workers, among others, who work together with primary care teams to support and develop health practices in the population ¹¹11 . Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Diretrizes do NASF: Núcleo de Apoio a Saúde da Família. Brasília: Minsitério da Saúde; 2006. (Caderno de Atenção Básica, 27)..

The promotion of physical activity has been encouraged in accordance with primary health care policies ¹²12 . Ministério da Saúde. Política Nacional de Atenção Básica. Brasília: Ministério da Saúde. 2006.. For example, in April 2011, the Brazilian Ministry of Health launched the Academia da Saúde (Health Gym) program which designated specific spaces for physical activity in Brazilian municipalities within the primary care framework ³3 . Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet 2012; 380:247-57.^,88 . Malta DC, da Silva JB. Policies to promote physical activity in Brazil. Lancet 2012; 380:195-6.^,1313 . Orrow G, Kinmonth AL, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 2012; 344: 1-17.^,1414 . Siqueira FV, Facchini LA, Piccini RX, Tomasi E, Thumé E, Silveira DS, et al. Atividade física em adultos e idosos residentes em áreas de abrangência de unidades básicas de saúde de municípios das regiões Sul e Nordeste do Brasil. Cad Saúde Pública 2008; 24:39-54.. In addition, physical activity interventions have been carried out as a strategy to promote health in this setting ¹⁵15 . Rodrigues JD, Ferreira D, Silva P, Caminha I, Farias Junior JC. Inserção e atuação do profissional de educação física na atenção básica de saúde: revisão sistemática. Rev Bras Ativ Fís Saúde 2013; 18: 5-15.^,1616 . Nakamura PM, Papini CB, Chiyoda A, Gomes GAO, Valdanha Netto A, Teixeira IP, et al. Programa de intervenção para a prática de atividade física: Saúde Ativa Rio Claro. Rev Bras Ativ Fís Saúde 2010; 15:128-32..

Existing programs have behavioral, environmental and educational components. They occur in accordance with the socioeconomic and cultural differences found in each municipality. Several types of interventions have been utilized including informational lectures, supervised physical activities, and counseling by health professionals ¹⁷17 . Kallings LV, Leijon M, Hellanius ML, Stahle A. Physical activity on prescription in primary health care: a followingup of physical activity level and quality of life. Scand J Med Sci Sports 2008; 18: 154-61.^,1818 . Aittasalo M, Miilunpalo S, Kukkonen-Harjula K, Pasanen M. A randomized intervention of physical activity promotion and patient self-monitoring in primary health care. Prev Med 2006; 42:40-6.. International studies have shown a positive relationship between participation in programs to increase physical activity and levels of physical activity, as well as improvements in health conditions of the population ¹⁷17 . Kallings LV, Leijon M, Hellanius ML, Stahle A. Physical activity on prescription in primary health care: a followingup of physical activity level and quality of life. Scand J Med Sci Sports 2008; 18: 154-61.^,1919 . Lawton BA, Rose SB, Elley CR, Dowell AC, Fenton A, Moyes SA. Exercise on prescription for women aged 40-74 recruited through primary care: two year randomised controlled trial. Br J Sports Med 2009; 43:120-3.. Much of this evidence on effective community physical activity programs comes from Brazil ²⁰20 . World Bank. Brazil addressing the challenge of non-communicable diseases in Brazil. https://openknowledge.worldbank.org/handle/10986/ 8334 (accessed on 11/Jan/2014).
https://openknowledge.worldbank.org/hand... ^,2121 . Hallal PC, Tenório MCM, Tassitano RM, Reis RS, Carvalho YM, Cruz DKA, et al. Avaliação do programa de promoção da atividade física Academia da Cidade de Recife, Pernambuco, Brasil: percepções de usuários e não-usuários. Cad Saúde Pública 2010; 26:70-8.^,2222 . Hallal PC, Carvalho YM, Tassitano RM, Tenório MCM, Warschauer M, Reis RS, et al. Quali-quantitative evaluation of the ‘Academia da Cidade’ program from Recife, Brazil: perceptions of the professionals working in the program. Rev Bras Ativ Fís Saúde 2009; 14:104-14.^,2323 . Simoes EJ, Hallal P, Pratt M, Ramos L, Munk M, Damascena W, et al. Effects of a community-based, professionally supervised intervention on physical activity levels among residents of Recife, Brazil. Am J Pub Health 2009; 99:68-75.^,2424 . Gomes MA, Duarte MDFDS. Efetividade de uma intervenção de atividade física em adultos atendidos pela estratégia saúde da família: Programa Ação e Saúde Floripa-BRASIL. Rev Bras Ativ Fís Saúde 2008; 13:44-66..

Recent meta-analyses of randomized clinical trials of physical activity counseling and referral programs indicate that this approach can be effective in helping inactive individuals become more active and to meet current physical activity recommendations ¹³13 . Orrow G, Kinmonth AL, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 2012; 344: 1-17.^,2525 . Williams NH, Hendry M, France B, Lewis R, Wilkinson C. Effectiveness of exercise-referral schemes to promote physical activity in adults: systematic review. Br J Gen Pract 2007; 57:979-86.. Regular physical activity counseling by primary care providers is a national public health objective in the United States of America ²⁶26 . US Department of Health and Human Services. Healthy People 2020. http://www.healthypeople.gov/2020/default.aspx (accessed on 12/Jan/2014).
http://www.healthypeople.gov/2020/defaul... . In addition, physical activity counseling has been shown to be cost-effective, and is part of primary care systems in the United Kingdom ²⁷27 . Murphy SM, Edwards RT, Williams N, et al. An evaluation of the effectiveness and cost effectiveness of the National Exercise Referral Scheme in Wales, UK: a randomised controlled trial of a public health policy initiative. J Epidemiol Community Health 2012; 66:745-53., Sweden and Switzerland ²⁸28 . Wanner M, Martin-Diener E, Bauer GF, Stamm H, Martin BW. Allez Hop, a nationwide programme for the promotion of physical activity in Switzerland: what is the evidence for a population impact after one decade of implementation? Br J Sports Med 2011; 45:1202-7.. In general, participation in a physical activity program in primary health care in Brazil starts with counseling from a health professional (physician, nurse, community worker), followed by an invitation to participate in a program sponsored by the primary care unit. Program awareness in many cities is also enhanced through special events and community educational activities performed by the health units ¹⁶16 . Nakamura PM, Papini CB, Chiyoda A, Gomes GAO, Valdanha Netto A, Teixeira IP, et al. Programa de intervenção para a prática de atividade física: Saúde Ativa Rio Claro. Rev Bras Ativ Fís Saúde 2010; 15:128-32..

However, to our knowledge there are few reports describing physical activity counseling and referral schemes in the primary care settings in middle income countries such as Brazil ¹⁶16 . Nakamura PM, Papini CB, Chiyoda A, Gomes GAO, Valdanha Netto A, Teixeira IP, et al. Programa de intervenção para a prática de atividade física: Saúde Ativa Rio Claro. Rev Bras Ativ Fís Saúde 2010; 15:128-32.^,2424 . Gomes MA, Duarte MDFDS. Efetividade de uma intervenção de atividade física em adultos atendidos pela estratégia saúde da família: Programa Ação e Saúde Floripa-BRASIL. Rev Bras Ativ Fís Saúde 2008; 13:44-66.^,2929 . Silva MP, Santos JWD, Souza AN, Tempesta SD, Avelino RA. Programa multidisciplinar para promoção da saúde envolvendo atividade física supervisionada: ações do PAFIPNES na atenção a saúde de mulheres em uma Unidade Básica de São José do Rio Pardo-SP. Rev Bras Ativ Fís Saúde 2011; 16:362-6.. An in-depth overview of the FHT physical activity program in Brazil may help guide future actions to maintain and improve existing programs, evaluate their effectiveness and cost-effectiveness, and encourage research that leads to the replication or implementation of similar interventions in other low-to-middle income countries. Thus, the objective of this study was to describe the characteristics of physical activity interventions implemented in primary health care units in Brazil.

Methods

This study was developed by GUIA (Guide for Useful Interventions for Physical Activity in Latin America), a project designed to assess and promote evidence-based strategies to increase physical activity in Latin America ³⁰30 . Pratt M, Brownson RC, Ramos LR, Malta DC, Hallal PC, Reis RS, et al. Projeto GUIA: a model for understanding and promoting physical activity in Brazil and Latin America. J Phys Act Health 2010; 7 Suppl 2:S131-4.^,3131 . Parra D, Hoehner C, Hallal P, Reis RS, Malta DC, Pratt M, et al. Scaling up of physical activity interventions in Brazil: how partnerships and research evidence contributed to policy action. Glob Health Promot 2014; 20:5-12.. A cross-sectional study was conducted with a random-digit-dial telephone survey directed at physicians, nurses, community health workers and managers working in primary health care units in Brazil. These units were classified as Family Health, Traditional, or Mixed (Traditional units with FHS) according to the presence or absence of the FHS program. We did not consider the number of Family Health programs in each health unit in this study. Unlike the units within the FHS in which a multi-professional NASF team is employed, traditional units are not composed of diverse professional teams and are based on care provided in medical consultation. The primary sampling frame included the 42,486 primary health care units in the Brazilian Ministry of Health registry (Cadastro Nacional de Estabelecimentos de Saúde – CNES. http://cnes.datasus.gov.br, accessed on 02/Jan/2011). The sample consisted of 1,600 randomly selected primary health care units covering all regions of the country. The sample was representative of all Brazilian health units (Table 1). For the sample size, a prevalence of 50% of health units with physical activity programs was considered, and a four percentage points error; at least 600 health units were required to detect a meaningful difference, and our sample selection surpassed this number.

The interviews were carried out by six, trained interviewers from the Federal University of Pelotas (UFPel). The maximum duration of each interview was 40 minutes. Data collection occurred between January and July 2011. Coordinators were asked about physical activity interventions because not all units have a specific professional for physical activity, and coordinators will likely have an overview about all health promotion strategies in their units. The coordinators of all selected units were invited to attend an interview, and then to contact a doctor, nurse, or community health worker drawn from their respective facilities. For this study, we used only data related to the health unit coordinators.

Coordinators responded to an open-ended and multiple-choice questionnaire of yes or no questions related to the operation of health facilities, the presence or absence of interventions aimed at increasing physical activity, and the characteristics of such programs. For this study we analyzed only the units that had some type of intervention for physical activity, subject to the absence or presence of NASF in the city, and by region of Brazil. Other variables included: all types of physical activity programs, frequency and duration of activities, a professional that supervised the activities, the presence of extra events, activities for school children, time of day the events occurred, sites where the physical activity took place and the perceived quality of the programs.

All data were entered into the version 3.1 of the Epidata program (Epidata Assoc., Odense, Denmark) and then transferred to Stata, version 12.0 (Stata Corp., College Station, USA). An analysis of the consistency and missing values was performed. We carried out a descriptive analysis using absolute and relative frequencies. These proportions were described according to the stratification. This study was approved by the Ethics Research Committee of the School of Physical Education/UFPel (n. 16154).

Results

The coordinators response rate was 78%. Of the 1,600 primary care units initially contacted, 1,251 participated in the survey, of which 495 (39.5%) reported the existence of physical activity interventions. Out of the 1,251 primary care units, a total of 60.7% were FHS, 23.6% traditional, and 15.7% mixed.

Table 2 shows the comparison of units with and without physical activity interventions according to the presence or absence of NASF in the city and regions of Brazil. Units without NASF (32.8%) had less physical activity interventions compared to units with NASF (50%) (p < 0.001). Among the units with physical activity referral interventions, the largest proportions were found in the Southeast (50.3%) region (p < 0.001) and the smallest proportion in the North (21%). In the cities with NASF, the prevalence of health units with physical activity interventions distributed by region were 41.0% in the Northeast, 34% in the Southeast, 12.3% in the South, 9.4% in the Central West and 3.3% in the North.

Table 3 presents the absolute and relative frequency of the operating characteristics for all units. Most coordinators reported more than one type of physical activity intervention. In total, 1,762 types of intervention were found. Walking groups was the most frequent type of physical activity intervention (81.1%). The most common weekly frequency for physical activity programs was once a week (33.1%), lasting from 30 minutes to an hour (51.4%) (Table 3). Physical education professionals were responsible for overseeing physical activity programs in 48.8% of primary health units. In a large portion of units, other health professionals (physicians, nutritionists, and physiotherapists) also guided activities. Approximately 60% of the units performed additional activities in the form of lectures and courses (45.5%). Most units did not carry out activities for school children (81.8%). Most activities occurred within the health unit (55.5%), followed by churches/associations/community centers (53.1%) and sidewalks/streets (43.7%). Pools (7.3%) and bike paths (3.9%) were less frequently cited as spaces for physical activity interventions. The proportion of coordinators that considered the quality of the primary care unit’s physical structure to be good/adequate was 52.1%.

The characteristics of the physical activity interventions according to the presence or absence of NASF in the city are also presented in Table 3. Similar proportions were found in the types of physical activity offered in both groups, except for “stretching and relaxation” activities (> 10% difference). The most common activities were walking and “stretching and relaxation” exercises (80.6% and 71%, respectively) among units with NASF. The least frequent activity was capoeira (< 3% in units with and without NASF). The average duration of most classes was 30-60 minutes in 57.5% of NASF units versus 49.2% in units without NASF. In 54.5% of NASF units, physical education professionals supervised physical activity versus 44% in units without NASF. A large proportion of other professionals were responsible for this supervision in both situations (presence = 52% and absence = 45.2%). Additional activities were most often held in units without NASF in the city (61.9%), and physical activity lectures/courses were more prevalent (47.6%). Approximately 84.8% and 80.4% of units with or without NASF in the city have not developed activities for school children. Among the units that were developing these activities, 64.8% were performed during the week, most of them outside of school hours for the units with NASF and 61.9% for units without NASF in the city. Table 4 shows the characteristics of the places used for physical activity interventions. As it relates to where the physical activity was performed, the proportions were similar between units with and without NASF, most of which took place at the health unit (53.2% and 57.3%), churches/community centers (51.2% and 53.3%), and sidewalks/streets (45.2% and 46.7%), respectively. Bike paths were less commonly used for physical activity interventions in both cases (2.3% and 5.5%). A higher proportion of coordinators from units with NASF reported good/adequate quality structures compared with those from units without NASF (53.5% and 49.7%).

The characteristics of the interventions by region are presented in Table 5. The most common type of physical activity reported was walking groups from those in the Central West region (93%). The North region presented the lowest frequency of physical activity interventions. In addition to these activities, the North had the highest frequency of stretching/relaxation (82.4%), while the Northeast had the highest proportions of physical assessments (70.7%) and fitness classes (49.7%). The highest and lowest weekly frequencies of physical activities were twice a week in the North (46.2%) and four times per week in the Central West (5.1%). Few units from all regions had classes lasting less than 30 minutes. The Central West region had the highest proportion of units with classes lasting 30-60 minutes (63.6%), while most of the lessons in the Northeast took over an hour (57.5%). The majority of classes were held in the morning in all regions, most frequently in the North (94.1%). The highest proportion of afternoon classes was reported in the South (66.7%). Physical education professionals were responsible for guiding physical activity in most regions, especially in the South (57.7%). In the North region other professionals were mostly engaged in physical activity promotion (70.6%). This region was also where more extra events occurred (62.7%), mostly in the form of lectures/courses (51.7%). The regions reporting no physical activity programs for children with the highest and lowest proportion were the Southeast (85.4%) and South (75%). Most activities happened outside of school hours (75%). Table 6 depicts the perceptions of coordinators as to where activities take place by region. In the North, activities occurred more frequently on sidewalks/streets (80%) and walking tracks (60%). In the Southeast, activities occurred more frequently in the health unit (50%) and in squares and parks (47.6%). The rating of physical spaces as good/adequate by coordinators ranged from 35% (Central West) to 60% (North).

Discussion

This is the first study to investigate physical activity interventions within the SUS in Brazil using a nationally representative sample. Data from this study showed that four out of ten primary care units offered physical activity promotion programs, while units with NASF in the city had a larger proportion of physical activity interventions. We also found more physical education professionals supervising physical activities in units in cities without NASF. This finding was somewhat unexpected given that NASF policies include physical education professionals and that physical activity interventions are anticipated in cities with NASF. This might be due to the fact that NASF guidelines were created only three years ago ³²32 . Departamento de Análise de Situação em Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Avaliação de efetividade de programas de atividade física no Brasil. Brasília: Ministério da Saúde; 2011. and the presence of physical activity programs was independent of NASF. In addition, the expansion of the NASF started exactly when the data collection happened and a general question was asked about the presence of NASF in the city, thus we do not know exactly if the selected health units were linked with the NASF team at that time. As such, there was a limitation to understanding the relationship between the presence of NASF and the existence of physical activity interventions.

Regarding the types of physical activity programs offered, walking groups were reported to be the most common activity in our study. These data are in line with the history of physical activity in the Brazilian primary care system. Walking groups have been used as a strategy for promoting health among high-risk groups (e.g. diabetes, hypertension) and have been in place since the 1990s ⁷7 . Knuth AG, Malta DC, Cruz DK, Freitas PC, Lopes MP, Fagundes J, et al. Rede nacional de atividade física do Ministério da Saúde: resultados e estratégias avaliativas. Rev Bras Ativ Fís Saúde 2010; 15:229-34.. The presence of these groups has been stable ⁷7 . Knuth AG, Malta DC, Cruz DK, Freitas PC, Lopes MP, Fagundes J, et al. Rede nacional de atividade física do Ministério da Saúde: resultados e estratégias avaliativas. Rev Bras Ativ Fís Saúde 2010; 15:229-34. and has been supported by public policies that encourage physical activity in Brazil, especially the National Policy for the Promotion of Health ⁸8 . Malta DC, da Silva JB. Policies to promote physical activity in Brazil. Lancet 2012; 380:195-6.^,1212 . Ministério da Saúde. Política Nacional de Atenção Básica. Brasília: Ministério da Saúde. 2006.^,3232 . Departamento de Análise de Situação em Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Avaliação de efetividade de programas de atividade física no Brasil. Brasília: Ministério da Saúde; 2011.. This policy is characterized by an equity incentive, social participation, the capacity building of health professionals, and the dissemination and exchange of successful practices. The policy has guided actions of primary health care around the country, which may have contributed to the maintenance of these groups ²²22 . Hallal PC, Carvalho YM, Tassitano RM, Tenório MCM, Warschauer M, Reis RS, et al. Quali-quantitative evaluation of the ‘Academia da Cidade’ program from Recife, Brazil: perceptions of the professionals working in the program. Rev Bras Ativ Fís Saúde 2009; 14:104-14..

However, there was a wide range of variation for the functional characteristics of health facilities according to different regions of the country. This fact can be explained by the socioeconomic and cultural differences between regions, which according to some studies determine the performance of actions in the primary health care system ³³33 . Facchini LA, Piccini RX, Tomasi E, Thumé E. Desempenho do PSF no Sul e no Nordeste do Brasil: avaliação institucional e epidemiológica da Atenção Básica à Saúde. Ciênc Saúde Coletiva 2006; 11:669-81.^,3434 . Facchini LA, Piccini RX, Tomasi E, Thumé E, Teixeira VA, Silva DS, et al. Avaliação de efetividade da Atenção Básica a Saúde em municípios das regiões Sul e Nordeste do Brasil: contribuições metodológicas. Cad Saúde Pública 2008; 24 Suppl 1:S159-72.. The Northeast region was noted for having more structured interventions and frequent physical assessments, offering more physical activities, and having a greater number of physical education professionals guiding activities. In line with these data, the health promotion network of the SUS, funded by the Brazilian Ministry of Health after 2005, underwent a large expansion in the Southwest and Northeast regions of the country ⁷7 . Knuth AG, Malta DC, Cruz DK, Freitas PC, Lopes MP, Fagundes J, et al. Rede nacional de atividade física do Ministério da Saúde: resultados e estratégias avaliativas. Rev Bras Ativ Fís Saúde 2010; 15:229-34.. In addition, the Northeast was the first region in the country in which the FHS was implemented, and involved the expansion of strategic actions in the community ¹⁰10 . Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios. Um panorama da saúde no Brasil: acesso e utilização de serviços, condições de saúde e fatores de risco e proteção à saúde, 2008. Brasília: Instituto Brasileiro de Geografia e Estatística; 2008.. Factors such as climate, average temperatures and work organization may explain the difference in results between regions, regarding the time of the day the classes were offered (morning or afternoon).

Physical activity recommendations to improve health outcomes in adult populations call for at least 150 minutes per week of moderate intensity physical activity, 75 weekly minutes of vigorous activity, or an equivalent combination, in addition to strength training and stretching activities twice per week ³⁵35 . Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc 2011; 43:1334-59.. These recommendations have also been recommended in health promotion policies in Brazil. Offering physical activity in primary care settings is very relevant since it benefits vulnerable populations that need access to health promotion and non-communicable disease control. Findings from this study showed that most units do not offer the minimum weekly volume of physical activity required according to international recommendations (at least 150 minutes of moderate physical activity per week) ³⁵35 . Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc 2011; 43:1334-59.. However, achieving physical activity recommendations is not the primary goal of interventions in primary care settings. They can also include strategies to change behavior towards physical activities and awareness about the health benefits of physical activity, which are in accordance with the health promotion policies established in this setting. In addition, units do offer events through lectures and courses that can lead to greater awareness and knowledge about the importance of achieving physical activity guidelines for health benefits. As a consequence, it is possible that individuals would feel better prepared and encouraged to engage in additional bouts of physical activity and exercise outside of the referral system and health facilities, thus the role of primary care in increasing physical activity levels would be fulfilled through outreach programs and activities ¹³13 . Orrow G, Kinmonth AL, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 2012; 344: 1-17.^,1717 . Kallings LV, Leijon M, Hellanius ML, Stahle A. Physical activity on prescription in primary health care: a followingup of physical activity level and quality of life. Scand J Med Sci Sports 2008; 18: 154-61.^,3636 . Fleming P, Godwin M. Lifestyle interventions in primary care. Can Fam Physician 2008; 54:1706-13..

This study showed that physical education professionals led most of the physical activity programs. Similar findings have been reported by the Physical Activity National Network of Brazil, which found that in 1,500 municipalities receiving funding for physical activity interventions, physical education professionals directed 91.5% of the programs ⁷7 . Knuth AG, Malta DC, Cruz DK, Freitas PC, Lopes MP, Fagundes J, et al. Rede nacional de atividade física do Ministério da Saúde: resultados e estratégias avaliativas. Rev Bras Ativ Fís Saúde 2010; 15:229-34.. Physical education has been recognized as a health profession in Brazil since 1998 and has been identified in the proposed policies as part of the NASF team ¹¹11 . Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Diretrizes do NASF: Núcleo de Apoio a Saúde da Família. Brasília: Minsitério da Saúde; 2006. (Caderno de Atenção Básica, 27).^,1212 . Ministério da Saúde. Política Nacional de Atenção Básica. Brasília: Ministério da Saúde. 2006.. In recent years, physical education professionals have increasingly acted in the context of prevention and control of non-communicable diseases (NCD). In terms of physical activity, the data from this study also revealed that other health professionals have collaborated significantly in this process, mainly in the North. Among these, users specifically have praised the community health worker as the most outstanding professional category, possibly due to the proximity of their work with the community ³⁷37 . Ronzani TM, Silva CM. O Programa Saúde da Família segundo profissionais de saúde, gestores e usuários. Ciênc Saúde Coletiva 2008; 13:23-34.. Teamwork within primary care is recommended in the National Primary Health Care guidelines ¹¹11 . Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Diretrizes do NASF: Núcleo de Apoio a Saúde da Família. Brasília: Minsitério da Saúde; 2006. (Caderno de Atenção Básica, 27).. The importance of conducting multidisciplinary work in this context has stimulated a collective effort from the entire team to solve the most common problems and prioritize high-risk groups through educational activities and the implementation of health promotion strategies which may help explain our results ¹²12 . Ministério da Saúde. Política Nacional de Atenção Básica. Brasília: Ministério da Saúde. 2006.^,3838 . Ferreira AS. Competências gerenciais para unidades básicas do Sistema Único de Saúde. Ciênc Saúde Coletiva 2004; 9:69-76.^,3939 . Ogata MN, Machado MLT, Catoia EA. Saúde da família como estratégia para mudança do modelo de atenção: representalções sociais dos usuários. Revista Eletrônica de Enfermagem [Online] 2009; 11:820-9.. In addition to physicians and other primary care providers, physical education professionals, other exercise specialists and community health workers are therefore a very useful and untapped resource for the promotion of physical activity in primary care systems. They also have a role to play in providing links to community resources, as advocated by global programs such as the Exercise is Medicine initiative ⁴⁰40 . American College of Sports Medicine. Exercise is Medicine. http://exerciseismedicine.org/ (accessed on 05/Mar/2013).
http://exerciseismedicine.org/... ^,4141 . Sallis RE. Exercise is medicine and physicians need to prescribe it! Br J Sports Med 2009; 43:3-4..

The data also showed that most units do not offer physical activities for school children. In a systematic review of physical activity interventions in Latin America, Hoehner et al. ⁴²42 . Hoehner CM, Soares J, Parra DP, Ribeiro IC, Joshu CE, Pratt M, et al. Physical activity interventions in Latin America: a systematic review. Am J Prev Med 2008; 34:224-33. and Lobelo et al. ⁴³43 . Lobelo F, Garcia I, Holub CK, Nagle BJ, Arredondo EM, Barquera S, et al. School-based programs aimed at the prevention and treatment of obesity: evidence-based interventions for youth in Latin America. J School Health 2013; 83:668-77. reported that physical education classes in elementary school are effective in increasing physical activity levels among children. Furthermore, school-based and health care based interventions have also been shown to be effective for the prevention and management of obesity in Latin America and among Latinos in the US ⁴⁴44 . Holub C, Elder J, Arredondo E, Barquera S, Eisenberg CM, Romero LMS, et al. Obesity prevention among Latinos in the U.S. and Latin America: a systematic literature review. Am J Prev Med 2013; 44:529-37.^,4545 . Holub CK, Lobelo F, Mehta SM, Sánchez Romero LM, Arredondo E, Elder JP. School-wide programs aimed at obesity among Latino youth in the United States: a review of the evidence. J School Health 2014; 84:239-46.. This highlights the need for encouraging the development and implementation of physical activity referral programs for children and young people by ensuring coordination between the primary health care system and schools.

With regard to the quality of the program’s infrastructure, Bauman et al. ⁴⁶46 . Bauman AE, Reis RS, Sallis JF, Wells JC, Loos RJF, Martin BW. Correlates of physical activity: why are some people physically active and others not? Lancet 2012; 380:258-71. suggest that environmental factors may determine more effective results in physical activity programs. Inadequate facilities may be an important reason for the lack of programs in these regions. The evaluation results on the physical characteristics of the sites were different between regions of the country in this study; 40 to 65% of coordinators are dissatisfied with the quality of the facilities where physical activity programs are offered.

There are limitations to be noted in this study. Some of these are intrinsic to the research which involved a telephone survey and used questionnaires. These methods included comprehensive questions that do not allow for more in depth information with regard to some important issues and may introduce desirability or other biases associated with self-reports. We did not develop a method of data validation, which limits the interpretation of our results. Considering that physical activity interventions can occur in many ways, it was not possible to identify, for example, if the physical activity programs reported were structured, had supervised classes or details on physical activity counseling given by the health professionals. This study was also unable to conclude if weekly frequency of programs which offered classes more than four times per week was referring to classes on the same day or different days. Since the coordinator reported more than one type of physical activity intervention, we were not able to know which one they were referring to for example the frequency or duration of the classes. In addition, it was not possible to know if the facilities in the primary centers were created specifically for physical activities or if it was necessary to adapt rooms, parking areas or corridors in the units. Further studies should explore these issues in more depth through qualitative studies and objective assessments ⁴⁷47 . Hallal PC, Knuth AG. Physical activity and the need of qualitative research. Rev Bras Ciênc Esporte 2011; 33:181-92.. Lastly, it is possible that the coordinator’s report on the number of primary health care units with physical activity referral interventions may have been overestimated, or some of them might have been carried out without any funding. Data from the Brazilian Ministry of Health reported that about 17% of municipalities were awarded funding for physical activity interventions in 2010, around half the figure reported by coordinators in this study ⁴⁸48 . Ministério da Saúde. Municípios com financiamento destinado à projetos de atividade física. Brasília: Ministério da Saúde; 2013.. In addition, from all selected municipalities for this study, 26.6% had funding from the Ministry of Health to carry out a physical activity intervention. The coordinators probably considered counseling, lectures, education groups, and campaigns about physical activity as physical activity interventions.

There are limitations when it comes to comparing our data with other international studies because the link with the health care system is unique in Brazil. In addition, most of the international interventions in primary care settings use physical activity referral programs ¹³13 . Orrow G, Kinmonth AL, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 2012; 344: 1-17.^,1717 . Kallings LV, Leijon M, Hellanius ML, Stahle A. Physical activity on prescription in primary health care: a followingup of physical activity level and quality of life. Scand J Med Sci Sports 2008; 18: 154-61.^,1919 . Lawton BA, Rose SB, Elley CR, Dowell AC, Fenton A, Moyes SA. Exercise on prescription for women aged 40-74 recruited through primary care: two year randomised controlled trial. Br J Sports Med 2009; 43:120-3.^,2525 . Williams NH, Hendry M, France B, Lewis R, Wilkinson C. Effectiveness of exercise-referral schemes to promote physical activity in adults: systematic review. Br J Gen Pract 2007; 57:979-86.^,3636 . Fleming P, Godwin M. Lifestyle interventions in primary care. Can Fam Physician 2008; 54:1706-13. and studies are focused on the effectiveness of physical activity interventions instead of describing their characteristics. The effectiveness of physical activity interventions is determined using supervised classes, personal or telephone counseling, education activities and pedometer use ¹⁸18 . Aittasalo M, Miilunpalo S, Kukkonen-Harjula K, Pasanen M. A randomized intervention of physical activity promotion and patient self-monitoring in primary health care. Prev Med 2006; 42:40-6.^,1919 . Lawton BA, Rose SB, Elley CR, Dowell AC, Fenton A, Moyes SA. Exercise on prescription for women aged 40-74 recruited through primary care: two year randomised controlled trial. Br J Sports Med 2009; 43:120-3.^,2525 . Williams NH, Hendry M, France B, Lewis R, Wilkinson C. Effectiveness of exercise-referral schemes to promote physical activity in adults: systematic review. Br J Gen Pract 2007; 57:979-86.^,3636 . Fleming P, Godwin M. Lifestyle interventions in primary care. Can Fam Physician 2008; 54:1706-13.. There is widespread evidence of the evaluation of physical activity interventions in Brazil ⁷7 . Knuth AG, Malta DC, Cruz DK, Freitas PC, Lopes MP, Fagundes J, et al. Rede nacional de atividade física do Ministério da Saúde: resultados e estratégias avaliativas. Rev Bras Ativ Fís Saúde 2010; 15:229-34.. Although a formal evaluation of effectiveness is pending, the extent and breadth of physical activity programs offered by the primary care health system in Brazil appears to have much potential to help reduce physical inactivity, a global priority to help control the rising burden of NCDs ⁴⁹49 . World Health Organization. Global action plan for the prevention and control of noncommunicable diseases, 2013-2020. Geneva: World Health Organization; 2013..

In conclusion, data from this study showed that four out of ten primary care units offered physical activity promotion programs. The characteristics of the physical activity programs in primary care in Brazil showed that activities included walking groups, physical assessments, stretching/relaxation exercises, and gym classes. Most activities occurred in the morning, with an average of one or two 30-minute weekly sessions. Physical education professionals were largely responsible for directing these activities. Primary care units usually offered additional informational activities, but most did not offer physical activities for school children. Most of the interventions occurred at the primary care unit and nearby community spaces. About half of the locations were evaluated as being good or adequate by the primary care unit coordinators.

Acknowledgments

The authors wish to thank all members of the GUIA team and the participating health care unit professionals. This study was funded through the Centers for Disease Control and Prevention’s Prevention Research Centers Program contract U48/DP001903 (Applying Evidence- Physical Activity Recommendations in Brazil). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC.

References

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