The impact of the physical inactivity pandemic is far-reaching and affects both individual health and societal well-being.1–3 Regular physical activity (PA) reduces the risk of noncommunicable diseases4 and attenuates the effects of prolonged sedentary behavior.5 Promoting PA with messages linked to preventing these diseases is currently a dominant narrative. Consequently, public health policies have emphasized the importance of active lifestyles in reducing noncommunicable diseases-related mortality through PA programs and initiatives.6,7
Implementing successful approaches to encourage PA not only diminishes the prevalence of diseases and health care expenses but can also offer untapped opportunities to reach physically inactive populations. Researchers, professionals, and public health institutions in general have taken measures to reverse the emerging setting of physical inactivity.8 Some public policy guidance documents have been published, including the World Health Organization’s Global Action Plan on PA in 2018,9 and the New PA Guidelines from the World Health Organization and individual countries.5 The PA Guide for the Brazilian population was published in 2021 as a strategy to support interventions delivered through the Primary Health Care (PHC).10
In Brazil, physical inactivity rates remain high, contributing significantly to the health care burden. Studies indicate that if a larger portion of the Brazilian population adopted an active lifestyle, substantial reductions in health care expenses could be achieved, alleviating strain on the public health system.11,12 The Brazilian health care system, known as the Unified Health System (SUS), is a system that provides health care access to the population. PHC in Brazil is structured to cover broad areas focusing on preventive, and community-based services to reach diverse, and, often, underserved populations. Given the widespread demographic diversity, our study offers insights that may also reflect health equity considerations.12 PHC system shows great potential for the development and implementation of initiatives to promote PA.11 This is due to the existence of a National Health Promotion Policy, which, among other things, seeks to promote PA in local communities.12 However, the implementation of PA initiatives within the scope of PHC is still a challenge for the field of public health. It is necessary to consolidate operational processes to promote PA in the daily lives of patients in PHC. This challenge becomes latent when we consider that, in addition to implementing it, it is necessary to think about sustainability strategies for the initiatives developed.6–8 A PA initiative that can present well-defined operational aspects, that are sustainable, and promotes the individual’s autonomy can be considered a successful PA initiative.13
The use of implementation science (IS) has significant potential for advancing PA initiatives in the PHC settings.14 IS can be defined as the scientific study of methods to promote the adoption of research findings into routine health care practices, with the clear goal of improving community health.14 By employing evidence-based strategies and principles from IS, health care services and professionals can more successfully integrate PA promotion into routine practices. Additionally, IS provides the frameworks for evaluating the effectiveness and scalability of PA initiatives in real-world health care settings, ultimately increasing the impact of PHC in promoting PA and improving overall health outcomes.15
In this context, the literature highlights some challenges: (1) the need to consider whether PA initiatives carried out in the context of PHC are successful and (2) there is an emerging need to better understand how to create strategies and support organizational processes for implementing PA initiatives developed in the context of public health. The Brazilian Ministry of Health, in partnership with researchers, health professionals, and health care managers, developed a technical document that presents 8 strategies for developing successful initiatives to promote PA within the primary health care setting.16 The strategies presented are divided into work processes that can be implemented in the routine of health care teams to make the PA initiative more successful.
The present manuscript aims to translate recommendations for the implementation of successful PA initiatives in PHC in Brazil from research to practice. It considers the proposal of organizational processes necessary to ensure successful PA initiatives. Therefore, it is expected that this study will provide valuable insights for health administrators and professionals, supporting health teams with the necessary knowledge to implement a range of strategies aimed at promoting a more physically active population, in the PHC context.
Methods
The present study is a descriptive manuscript about an intervention to increase or promote PA in a community setting, and also is a methodological study, which includes a macroproject intitled “Saúde a Partir de Atividades Físicas Exitosas—SAFE Research,” organized under the following 5 steps: (1) defining a concept of successful PA initiative, (2) identifying and ranking initiatives and processes throughout Brazil, (3) direct and systematic observation of initiatives with the highest scores, (4) development of recommendations based on the common processes seen in the initiatives with the best scores, and (5) implementation of recommendations for initiatives that are not yet successful.
The present work reports the 4 initial phases of this project, which concerns the primary development of a theoretical and methodological intervention tool with PA that supports health teams in developing processes that make PA initiatives more successful in the context of PHC. Figure 1 presents the steps of SAFE research from the elaboration of the concept of a successful PA initiative at PHC to the elaboration of the technical document of recommendations, ending with the implementation of the recommendations.
—SAFE research steps. PHC indicates Primary Health Care; SAFE, Saúde a Partir de Atividades Físicas Exitosas.
Citation: Journal of Physical Activity and Health 22, 4; 10.1123/jpah.2024-0546
In step 1, we identified what constitutes a successful PA initiative. We developed the concept of successful actions in PA in PHC using the conceptual analysis method proposed by Walker and Avant.17 We followed 4 steps: (1) concept selection, (2) objective determination, (3) identification of possible concept uses, and (4) attribute determination. We used documentary analysis, online questionnaires, workshops, and expert panels with participants, including managers, coordinators, health professionals, patients, and researchers from PHC across Brazil. From these procedures, the concept of successful PA initiative in PHC was defined as “an action that promotes increased PA among participants through a planned, replicable, and sustainable process that ensures and promotes participation and autonomy.”18
In step 2, the concept and its attributes from step 1 were triangulated with the dimensions of the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework, which has been translated and culturally adapted to Brazil.19 A questionnaire with 22 questions was adapted from a larger set of questions derived from the 5 dimensions of the framework to evaluate PA initiatives in the PHC scenario. The questionnaire was hosted in a website and invitations to respond were sent to various health establishments in the 27 federative units of the country, using contacts provided by the Ministry of Health of Brazil. The responses formed a database of 1645 PA initiatives. Data were analyzed via Item Response Theory20 and initiatives were ranked based on questionnaire responses. Each question was related to a process of carrying out the initiative. The questions had different values, with scores presented only when the theory was used.
In health research, Item Response Theory is often applied to validate questionnaires and scales, providing a nuanced understanding of how individual items function in measuring complex constructs. In this study, Item Response Theory was operationalized to assess responses collected from a questionnaire, ensuring that each item effectively contributed to measuring the intended outcomes of promoting PA within the PHC setting.20
In step 3, some of the initiatives that received the highest evaluation in step 2 were visited. The initiatives visited cover the 5 political-administrative regions of Brazil. In each region, at least one initiative was visited in a large city (more than 100 thousand citizens), and one initiative was visited in a small city (except for the central-west region). During these visits, 4 procedures were conducted: (1) systematic observation of the activities performed, (2) individual interview with the “facilitator” of the initiative, that is, the professional responsible for its execution, (3) group interview with the rest of the multiprofessional team involved with overarching concepts and allowing the interviewees to expand as necessary, and (4) individual interview with the municipal health manager. For the present study, data from the interview with the municipal health administrators were used to assess the role of municipal health management in facilitating the implementation of successful PA practices in the PHC setting of the Brazilian Health Public System.
Qualitative data was collected through voice-recorded interviews, which were then transcribed verbatim. We used Nvivo for transcription and analysis. To enhance the reliability of findings, data triangulation was employed, incorporating multiple sources and perspectives during the analysis. Qualitative content analysis was used to reduce and interpret the focus group findings. Each focus group transcript constituted a unit of analysis providing within case, and then across case comparison. Topics of technology acceptability that were outlined in the interview guide were extracted a priori for substantial coding. Data corresponding to each question were coded together. Coded data was entered into a data matrix to search for patterns across coding categories. Resulting categories were then compared against the entire study data set to determine enhanced explanation or interpretation of the outcome data.
Step 4 of the research involved drafting the recommendations document for the development of successful PA practices in PHC. These recommendations offer strategies built upon the attributes of the concept developed in step 1, utilizing the dimensions of the RE-AIM framework and the elements collected during the visits conducted in step 3. Following the drafting of recommendations, the material was handed over to the Brazilian Ministry of Health for formatting and publication in its final version.16
In step 5 of the research, a meticulous approach was taken, involving the use of tools and processes from the science of improvement to develop a proposal for implementing the recommendations. This proposal was monitored over 8 months by the study’s scientific team. The implementation occurred in PA initiatives that did not present a success score in the 5 political-administrative regions of Brazil. The process of implementing these recommendations followed criteria based on IS, which will be comprehensively detailed in another future manuscript.
SAFE research was approved by the Human Research Ethics Committee of the Federal University of Santa Catarina under number 2,572,260 on March 30, 2018 (registration number 80431717.0.0000.0121).
Results
This research led to the development of a guideline that thoroughly outlines each strategy, and the corresponding processes required for implementation. The document has been published by the Ministry of Health of Brazil and is available for full acess.16
Eight strategies have been developed, the basis of common aspects of the most successful PA initiatives (observed in step 3), related to the attributes of a successful PA promotion initiative in PHC (autonomy, participation, planning, replication, and sustainability), and the dimensions of RE-AIM. Each strategy presents a set of processes that can be systematically operationalized to make the PA initiative more successful. These are options for work processes that can be adopted to make the initiative more successful in the PHC setting. Health professionals must observe the following 8 essential strategies: (1) promote and invite to the initiative, (2) frequency and regularity to initiative, (3) physical assessment, (4) regularity to physical assessment, (5) feedback from the physical assessment, (6) control of Attendance, (7) investigate the reasons for quit, and (8) health management support.
Table 1 presents the suggested strategies and their respective processes that can be systematically implemented. It is expected that by implementing the following strategies, a PA promotion initiative can become more successful in the public health setting.
Description of the Strategies and Their Respective Work Processes for Developing Successful PA Initiatives in PHC, Related to Their Respective Constituent Elements Based on the RE-AIM Dimensions and the Attributes of a Successful PA Initiative in PHC Brazil, 2022
| Strategy to be executed | Processes for implementation in the PA initiative | RE-AIM dimensions | Successful initiative attribute |
|---|---|---|---|
| 1. Promote and invite to the initiative (at least 3 strategies) | • CHWs • Oral invitation in the community • Invitation at the appointment • Distribution of posters • Printed invitations | Reach | Participation |
| 2. Frequency and regularity to initiative (at least 2 strategies) | • Increase meetings at least 1 d a week • Increase PA at other times of the day • Group for sending messages to motivate PA • Group on social media to share photos of PA • Set weekly goals to increase PA • Encourage participation in sporting events in the community • Create a visual identity for the PA group • Encourage social PA support (family and/or friends) | Implementation | Replication |
| 3. Physical assessment (at least 2 strategies) | • Instruments for assessing PA levels • Questionnaires to assessment to PA levels • Accelerometers • Pedometers • Measuring blood pressure • Anthropometric measurements | Implementation | Planning |
| 4. Regularity to physical assessment (at least 2 strategies) | • The first assessment can be carried out in the first month of starting PA • The following assessments can be carried out every 6 mo • Schedule assessments and follow-ups at times other than PA • Request help from other health care professionals to assist with assessments • Ensure equipment for regularity and return of the participants on the assessments | Implementation | Planning |
| 5. Feedback from the physical assessment (at least 2 strategies) | • Present and discuss the assessment results individually • Analyze and discuss in group the results of participant assessments • Know the individual goals for PA (weight loss, hypertension control, and well-being) • Establish new goals for each person • Support to participants in monitoring their health conditions | Effectiveness | Planning |
| 6. Control of Attendance (at least one strategy) | • A paper for the participants to sign • Oral call of the names of participants registered • Registration of participation in the local surveillance system • Establish an absence cutoff point to consider a quit | Maintenance | Sustainability |
| 7. Investigate the reasons for quit (at least one strategy) | • Contact the participant by phone • Send an email asking for reasons for absences • Support from CWHs to looking the reasons for the quit • Record the reasons for the quit to discuss with the health care team • Adapt the initiative to reduce the chances of quitting • Suggest participation in another initiative available in the community | Adoption | Participation |
| 8. Health management support (at least one strategy) | • Provide for the health managers data on initiatives carried out • List possible alternatives that could solve the problems presented • Support from other health professionals for interdisciplinary and multidisciplinary practices • Report to health managers the real conditions to offer PA in community settings | Implementation | Autonomy |
Abbreviations: CHWs, Community Health Workers; PA, physical activity; PHC, Primary Health Care; RE-AIM, reach, effectiveness, adoption, implementation, and maintenance.
Discussion
The main objective of this article is to present and translate a set of structured recommendations that aim to increase the success of PA initiatives in the Brazilian PHC settings. By focusing on the integration the key strategies rooted in IS, this study seeks to provide actionable guidance for health professionals and health administrators in PHC.
The recommendations result in a combination of 8 strategies: to promote and invite to the initiative, frequency and regularity to initiative, physical assessment, regularity to physical access, feedback from the physical access, control of attendance, investigate the reasons for quit, and health management support. The strategies aim to make PA initiatives more successful. Moreover, the material seeks to provide processes that lead to the implementation of organized and structured strategies in the context of PHC. The strategies were based on real-life experiences developed within the public health system in various contexts across Brazil, and the processes outlined in the document offer contributions for health care professionals, municipal managers, and individuals participating in PA initiatives.
Understanding and investigating the work processes in PHC in Brazil is crucial due to the country’s continental dimensions, which result in a diversity of practices, realities, and initiatives.21,22 This diversity demands approaches that are adapted and sensitive to local needs, making research conducted in Brazilian PHC highly relevant and promising. Such research has the potential to support policies and practices that are more effective and equitable across the entire national and international territory. Furthermore, recommending that well-defined and planned strategies aimed at achieving tangible objectives help to implement defined work processes.
The first strategy presented is related to the promotion of the PA initiative and processes related to participant recruitment. Engaging and recruiting the public to PA initiatives is a complex process that needs to be fully explored if we are to achieve the value that these initiatives can offer.23 A systematic review sought to address this gap in the scientific literature by providing insights into what helps and hinders patients in engaging and enrolling in health interventions and services and presented that for carrying out processes related to promoting an intervention. It is necessary to consider aspects, such as type of intervention, type of participants, and how the intervention is configured.24
Community Health Workers (CHWs) play a crucial role in the Brazilian PHC system, especially in promoting health and facilitating access to preventive services. Their involvement is essential for implementing strategies aimed at increasing PA, as they serve as a bridge between the health care system and the community. This context helps to underscore their inclusion in our discussion.25,26 These professionals educate the community about the benefits of PA, connect people to local resources, provide individualized support, and integrate PA promotion with other health care services.26 Therefore, strengthening the partnership with CHWs to promote the PA initiatives is one of the most important processes related to the first strategy to improve the reach of more successful PA initiatives.
Concerning the strategy related to the frequency and regularity in offering the PA initiative, it is essential to consider these processes when thinking about the frequency and regularity of any health care initiative offered in the context of the PHC.27,28 Also, consistency is key to establishing healthy and lasting habits. By increasing the frequency of meetings and activities, a routine is created that facilitates ongoing participation and adherence.27 Additionally, offering a variety of activities throughout the day allows individuals to incorporate PA into their daily lives, overcoming potential barriers of time or availability. Group approaches, whether through motivational messages, social media, or sporting events foster mutual support and shared responsibility, essential elements for long-term engagement.29–31 Setting weekly goals and establishing a visual identity for the group instills a sense of purpose and belonging, while social support from friends and family strengthens community bonds and individual commitment.30 In essence, considering these processes ensures that PA initiatives are accessible, engaging, and sustainable, maximizing their positive impact on community health and well-being.
Considering the next strategy, incorporating protocols for PA assessment within PHC settings is paramount for developing successful PA initiatives in primary care. Usually, PA assessment is carried out from the perspective of treatment or rehabilitation for some health condition.32–34 However, it is necessary to think about physical assessment protocols linked to initiatives that promote PA, from a comprehensive assessment perspective and not linked to a disease. Utilizing a variety of assessment instruments such as questionnaires, accelerometers, pedometers, and anthropometric measurements allows health care professionals to comprehensively evaluate individuals’ PA levels and overall health status.35 The systematization of health assessments provides valuable data for personalized interventions and monitoring, which facilitates integrated health care. Furthermore, regular physical assessments, including measurements of blood pressure and anthropometrics, also contribute to early detection of health risks, being motivational strategies for achieving individual goals over time. By prioritizing the integration of PA assessment protocols within primary health care settings, health care providers can enhance the effectiveness and sustainability of PA initiatives, ultimately promoting better health outcomes and well-being in the community.
In addition to ensuring space, the next strategy reflects on the importance of regular physical assessment consultations in PHC for the development of successful PA practices. Starting assessments early, within the first month after starting PA, establishes a basis for monitoring progress and identifying potential health risks. Subsequent assessments every 6 months allow health care managers to track changes over time and adjust interventions accordingly.32,34 Scheduling assessments and follow-ups separately from PA sessions promotes consistency and reinforces the importance of health monitoring.36 Collaboration with other health care professionals can improve the quality and efficiency of assessments, ensuring comprehensive care.
Additionally, establishing spaces for feedback on the results of the PA assessment with the patient is important to the success of PA initiatives in PHC. Presenting and discussing individual assessment results allows for personalized insights and goal setting tailored to each participant’s needs, whether it is weight loss, hypertension control, or general well-being.37,38 Understanding individual PA goals allows health care professionals to align interventions with participants’ aspirations, promoting motivation and adherence. PA counseling is an inexpensive tool that can be incorporated into this strategy, especially in the PHC setting. Health professionals in PHC recognize and use this tool, in addition to having different mechanisms to advise PA.39 especially among CHWs.40 Additionally, offering counseling and support for monitoring health conditions empowers participants to take responsibility for their well-being, promoting a collaborative approach to achieving satisfactory health outcomes in the PHC context.
Implementing procedures, such as having participants sign a paper, conducting oral calls of registered names, and recording participation in local surveillance systems ensures accurate tracking of attendance.41 These processes are related to effective control of attendance. Establishing a cutoff point for absences helps identify individuals who may have discontinued participation, enabling proactive intervention strategies. By monitoring attendance closely, health care providers can identify patterns, address barriers to participation, and tailor support mechanisms to maximize engagement, and adherence, to PA programs in the PHC settings.
Understanding the reasons for abandoning participation in PA initiatives in PHC is important for the development of successful experiences. Employing strategies, such as contacting participants by phone, sending emails to inquire about absences, and recording reasons for withdrawal facilitates the collection of valuable information about the factors that contribute to discontinuation.42,43 Leveraging support from CHWs again can also help understand these reasons and adapt initiatives to address identified barriers, ultimately improving participant retention and the effectiveness of PA programs in health care settings.40 Additionally, suggesting participation in alternative community initiatives provides individuals with additional opportunities to engage in PA, contributing to the overall success of the program.
Finally, another strategy is to provide health administrators with data on the initiatives carried out. All strategies combined in the implementation of a successful practice of PA offer possible indicators to support decision making. A study has shown that the support of professional facilitators in health interventions promotes interdisciplinary and multidisciplinary collaboration and the effectiveness of health interventions.44 Finally, reporting to health care management the actual conditions for providing PA in community settings ensures transparency and accountability. This strategy facilitates the alignment of resources with community needs and, ultimately, contributes to the success of PA initiatives in primary care settings.
Strengths and Limitations
There are some limitations to the results of the present study. The sample from the first phase of the main research is not representative of the number of basic health units in Brazil. The difficulty in reaching local managers was a limitation, despite the support of the Brazilian Ministry of Health in providing contact databases and disseminating the research on government websites. Another limitation was in the phase of on-site visits to the selected PA practices. However, an intentional selection was adopted to ensure greater regional, socioeconomic, and cultural diversity in the country.
On the other hand, some strong points should be mentioned. Different professionals participated in the study phases, such as health professionals, health administrators, researchers, as well as the patients of the Brazilian health system. The different perceptions and analyzes of qualitative data, through IS, contributed to a robust conceptualization of the attributes of a successful practice and their definitions. Together, these strengths offer practical and comprehensive recommendations to improve the implementation of PA initiatives and qualify the work process in PHC. Finally, the results from evidence based on practices, which reinforces the different strategies for replication in different contexts.
Conclusions
Findings from this study highly suggest recommendations for implementing successful PA initiatives in Brazilian PHC: promote and invite to the initiative; frequency and regularity of initiative; physical assessment; regularity to physical assessment; feedback from the physical assessment; control of attendance; investigate the reasons for quit and health management support.
These combined strategies assist health care professionals in all steps of planning, executing, and evaluating such initiatives. The strategies were based on practical experiences in the PHC context in Brazil, which can potentially be replicated in low- and middle-income countries. Furthermore, the recommendations for successful PA practices make it possible to cover other initiatives in the field of health promotion so that they can be implemented in an organized, systematized way, and with robust processes in community interventions.
Acknowledgments
The authors also acknowledge the Secretariat of Primary Health Care of the Ministry of Health for their support during the development of the strategies presented in the base document of this manuscript. Funding source: This study is part of the research entitled “SAFE research,” which was financed by the National Council for Scientific and Technological Development (CNPq) and the Ministry of Health registered with the title “Recomendações de atividade física para a saúde a partir das práticas exitosas desenvolvidas no Sistema Único de Saúde,” process number 408068/2017-5, in the amount of R$ 506,800.00. Doctoral scholarships were funded by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—Brasil (CAPES). The views of the funding agency did not influence the content or conduct of research.
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