The World Health Organization (WHO) Western Pacific Region comprises 22 Pacific Island Countries and Areas (PICs). The region has experienced a major shift in disease burden: non-communicable diseases (NCDs) have overtaken communicable diseases and are a critical health and development issue (WPRO, 2009). In 2004, the PICs experienced economic consequences of NCDs totalling US$ 1.95 million (Hossain & Kawar, et al., 2007). The prevalence of NCD risk factors in the Pacific region is among the highest in the world (Colagiuri & Win Tin, 2009; Edwards & Frizelle, 2009; Hughes & Marks, 2009; SPC, 2004). The leading NCD risk factors in the Pacific have been identified as unhealthy diets, physical inactivity, tobacco use and alcohol misuse (SPC, 2010a; SPC & WPRO, 2009; WPRO, 2009). The prevalence of these primary risk factors and the high rates of intermediate risk factors (obesity, hypertension, hyperglycemia) portray the current and future NCD epidemic (SPC, 2010a). American Samoa, Tokelau and Nauru have overweight and obesity rates as high as 93,5% (WPRO, 2007a), 86,2% (WPRO, 2007b) and 82,2% (WPRO, 2007c) respectively and diabetes rates are found to be 47,3% in American Samoa (WPRO, 2007a), 33,6 % in Tokelau (WPRO, 2007b) and 32,1% in Micronesia (WPRO, 2008). The proportion of deaths from NCDs is projected to rise globally from 59 per cent in 2002 to 66 per cent in 2030 (Mathers & Loncar, 2005). High-income countries have experienced increases in life expectancy due to prevention and treatment measures.
While NCDs account for 60% of global deaths (WHO, 2008b), NCDs account for approximately 75% of deaths in the Pacific region (SPC & WPRO, 2007). A significant proportion of NCD morbidity, disability and premature deaths within the region could be prevented through population-based lifestyle interventions and the control of preventable risk factors (Epping-Jordan & Galea, et al., 2005; WHO, 2008a; WPRO & SPC, 2007).
The benefits of regular physical activity (PA) include reduced risk of heart disease, stroke, diabetes, osteoporosis and some cancers (Haskell & Lee, et al., 2007; U.S. Department of Health and Human Services, 2008) and is a key element in obesity prevention (Wareham, 2007). Moreover, PA is a critical component of energy balance and is associated with positive mental health (Ezzati & Lopez, et al., 2004). The WHO has recognized that physical inactivity is a global health concern (WHO, 2004). Recent data rank physical inactivity fourth in terms of risk factor-related
overall mortality burden (WHO, 2010a), being responsible for 6% of deaths globally after high blood pressure (13% of deaths globally) and tobacco use (9%) (WHO, 2009a). Hence, increasing population PA levels is one of the most promising strategies for improving population health and reducing NCD burden (Haskell & Blair, et al., 2009; Simon & Gonzalez, et al., 2009; WHO, 2008a).
Interventions to increase and sustain physical activity participation among populations are an important component of health promotion. This review provides a stock take of existing PA programs in PICs, aiming to facilitate the sharing of ideas, methods and experiences across the region. Moreover, the stock take intends to identify program scope, target and reach, so to examine best practices and improve national NCD prevention campaigns. Current gaps in program provision and population reach will be reviewed and guidance and directions for future PA program development and implementation will be provided.
Research on physical activity behaviour of Pacific islanders is scarce. This stock take describes physical activity programs in twenty out of twenty-two Pacific Island countries and thus contributes to the growing body of work in the field of Pacific NCD prevention. Few previously established programs have been evaluated in peer-reviewed studies. Monitoring and evaluation of programs is important in order to improve program effectiveness and improve population health. Research outcomes may provide evidence to further stimulate program implementation in other small island states or communities.
Various strategies were undertaken to identify current PA programs in the different PICs. Electronic literature searches on PA programs were undertaken in the Scopus, MEDLINE and SPORTdiscuss database. Searches used the following key words: Physical activity, physical inactivity, exercise, sport program, sport programme, sport programs, sport programmes, prevention of noncommunicable diseases, prevention of NCDs AND Pacific Islands, PICs, Oceania, Polynesia, Melanesia, Micronesia or the country name of the 22 PICs. Additionally, Google was searched to identify PA programs that had not been scientifically peer-reviewed.
Where programs / interventions were found, NCD focal persons of the Ministry of Health office from the respective country were contacted via telephone to report on and confirm current status of the program. Independently of literature searches, each NCD focal person of the Ministry of Health office of each PIC was contacted first via email, thereafter via telephone to provide information on current PA programs. A structured email template requested program information about the program’s name, guiding plan / NCD plan, aim, year, setting, target group, location and reach. The majority of Ministries of Health were reached (20/22); but two Ministries (Wallis and Futuna, French Polynesia) could not be reached.
Simultaneously, program information was sourced from NCD representatives from nineteen countries and other NCD agencies during the Pacific NCD Forum joint SPC-WHO meeting in Nadi, Fiji, 2009 (SPC & WPRO, 2009). A semi-structured interview template was developed containing questions on the professional role and location of the respondent, details of plans and documents relating to PA, background, aims and components of PA programs, target population(s), setting(s) and geographical area(s), process and impact evaluation, main achievements and challenges. Interview responses were recorded and collated into a summary format for each country. Country summaries were then emailed to the relevant interviewee for review and comment, and additional relevant information was requested for inclusion.
Program reach has been operationalised as an absolute number of individuals of the target population in accordance to the first stage of the RE-AIM framework (Glasgow & Vogt, et al., 1999; Kaiser Permanente Colorado Region), thus representing the target population.
NCD representatives from the Secretariat of the Pacific Community (SPC) and from the World Health Organization Office of the South Pacific (WHO SP) were contacted for additional information.
Findings / results
Table 1 presents details of the PA programs. Key information is arranged according to country, specifying the title of each program, guiding plan, aims, year of commencement, setting, target group, location and reach where available. These attributes allow a summary to be made of Pacific regional PA programs.
Programs were designed by local authorities and developed within local and cultural realities. Traditional activities such as beach walks, (traditional) dancing, canoeing and swimming were as much represented as modern activities such as aerobics, gym attendance and awareness walks.
A total of 84 PA programs were described across 20 of the 22 PICs. Of these, 48 programs in 17 countries were confirmed during the interviews at the Pacific NCD forum in Nadi, Fiji 2009. The other 36 programs were confirmed by Ministry of Health officials through telephone conversations and email correspondence. Three countries were involved in delivering one PA program; 17 countries delivered multiple programs.
Whilst no country had adopted a specific national PA plan guiding programs, in the majority of countries (18/22), PA was a component of a wider NCD, obesity or lifestyle plan, with countries at different stages in the development of national NCD plans. Several countries were implementing programs in conjunction with the Pacific Physical Activity Guidelines (WPRO & SPC, 2008).
The majority (28) of the programs’ aims related directly to PA such as meeting the PA guidelines (Haskell & Lee, et al., 2007; WPRO & SPC, 2008) or, more generally, to increase PA levels. Ten programs’ aims were broader in reducing NCD risk factors, preventing obesity or promoting a healthy lifestyle. In addition to PA and NCD objectives, two countries cited increased social cohesion as key aims of PA programs.
Of the 84 programs, 26 took place in the workplace setting, 17 occurred in the school setting, 37 in the community setting and four in a clinical or health sector setting. Thirty one programs, mainly workplace programs, took place in urban areas only. Another 31 programs occurred in both urban and rural areas and 7 programs only occurred in village communities in rural areas. Location was unknown for 15 programs.
Key achievements of programs include increased awareness of environments for walking, increased awareness and interest in PA and higher walking participation in communities. Challenges encountered included limited time, lack of financial resources, human resource constraints, limits to venues and equipment and necessary skills and resources for evaluation. Communication in relating PA to health benefits, motivation of participants, changing attitudes and cultural constraints (e.g. female involvement in PA) were found to be challenges. Difficulties in reaching hard-to-reach groups such as those of low socioeconomic status and rural populations were often a reality. Remote islands faced additional geographical barriers.
Environmental constraints such as unsafe conditions for walking due to absence of footpaths and street lighting, dangerous stray dogs, wet weather, high temperatures and acute health emergencies such as H1N1 influenza created additional challenges.
Regarding population reach, 13 programs were estimated to reach fewer than 100 participants, 17 programs reached 100-500 participants, nine programs reached 500-1000 participants, 13 programs reached over 1000 participants, three programs were estimated to reach the whole population. For 29 programs, the population reach was unknown or the concept of ‘reach’ did not apply.
Thirty one programs targeted community-dwelling individuals, 24 targeted adults in employment, 15 targeted school children, six targeted health service/PA professionals, five targeted adults at risk of NCDs, one targeted the whole population, one targeted villages, and one program targeted women.
Ministries of Health were often implementing programs working in partnership with multiple agencies such as other government departments of sport, education, parks, planning and public affairs, NGOs, local communities and traditional groups, WHO, SPC and international aid agencies such as Unicef, AusAid (Australian Government Overseas Aid program) and NZAid (New Zealand International Aid & Development Agency).
Cross-sectoral partnerships, a growing profile of PA among policy makers, high level government endorsement and community initiated programs were seen as indicators of program success. The ability to address PA and nutrition both together and independently was also regarded as a positive outcome of some projects.
Impact evaluation results such as weight loss, increases in PA and health independent of weight loss, reducing or ceasing medication were also measures of success in some programs. Smoking cessation among participants was another cited achievement. At the time of writing, 15 PICs have collected baseline population data through STEPS surveys (WHO, 2010c) to profile their NCD risk factors and disease prevalence (SPC & WPRO, 2007).
Table 1: Findings: PA programs in the Pacific Island Countries and Areas
This stocktake has identified a large number of PA programs across the Pacific region. This may be a country-level response towards the Tonga commitment to promote healthy lifestyles and supportive environments (WHO & SPC, 2003) and WHO’s development of the Global Strategy on Diet, Physical Activity and Health in 2004 (WHO, 2004). A workshop on the implementation of the Global Strategy on Diet, Physical Activity and Health in the Pacific was held in Suva, Fiji in 2006 (WPRO, 2006). The majority (51/84) of the defined programs in the Pacific islands have been implemented since 2006.
In most countries in the Pacific, national PA plans are usually embedded in national NCD plans, instead of a stand alone PA plan. Of note was that twelve countries had established NCD strategies and policies or are currently in the stage of development and implementation. The place of PA programs within NCD policy and planning is likely to serve as an effective and sustainable way of an integrated approach to NCD prevention and control but at times can also make intersectoral work more challenging. We recommend that programs continue to be embedded within relevant strategies.
Whilst 15 PICs have collected baseline population data through STEPS surveys (WHO, 2010c) to profile their NCD risk factors and disease prevalence (SPC & WPRO, 2007), these national NCD STEP surveys have yet to be repeated. The Fiji STEP survey, for example, was carried out in 2002 and is planned to be repeated in 2011. Recurrent STEP surveys are recommended as they can serve as reliable NCD surveillance tools.
Several countries are delivering programs across multiple settings, target groups and geographical locations. Focusing programs and their resources on particular groups, settings and locations may increase the likelihood that programs reach high-risk groups such as women, children, rural populations and older people.
Program reach findings reveal a wide range of numbers of participants taking part in programs, from small programs with under 50 participants to large programs reaching the entire population. However, for 26 programs reach is unknown. Direct enquiries via telephone and email about estimated reach did not reveal any information. Hence, the efficacy of the stock take is limited in that program reach is unknown in one third of the findings.
A major weakness of the findings is the lack of consistent evaluation procedures. Few attempts have been undertaken to systematically measure participants’ lifestyle behaviour, program participation and most importantly change in lifestyle behaviour and health outcome. Programs are not linked to population surveillance systems, such as the WHO NCD stepwise approach to surveillance (STEPS) survey (WHO, 2010c), the Mini-STEPS survey (minimised version of the WHO NCD STEPS survey for the community setting) (WHO, 2010b; WPRO, 2006) or the Health Behaviour and Lifestyle of Pacific Youth (HBLPY) survey (Phongsavan & Olatunbosun-Alakija, et al., 2005). These tools could provide standardised, quality NCD data and be used as ongoing surveillance for conducting impact evaluation.
It is essential to document reach and participation rates through process evaluation to measure program efficacy. Several programs reported time constraints and lack of technical expertise or resources for evaluation processes. Partnership support from funding agencies, universities and technical experts may aid in overcoming these barriers. More robust monitoring and evaluation may support future sustainability and program effectiveness. The SWOT analysis can be used to identify program strengths, weaknesses, opportunities and threats in order to assess program effectiveness. The RE-AIM framework can analyze essential program elements to improve sustainable adoption. Both SWOT and RE-AIM can serve as assessment tools.
Monitoring PA participation through self-reported or objective measures like pedometers, body mass index (BMI) and other anthropometrical measures occurs in some programs and their continued use is recommended. Systematic program evaluation is planned for some countries (SPC & WPRO, 2007) and recommended for all to profile patterns and prevalence of lifestyle characteristics so that interventions can be revised and cross-country comparisons be made.
Most countries reported achievements resulting from PA programs as positive outcomes. Achievements ranged from increased awareness and interest in PA, to visible increases in PA levels in communities, to government endorsements at the Presidential level and to a growing profile of PA among policy makers. However, no tangible outcomes of NCD risk changes, or increase in health-related PA has been recorded. It is recommended to standardize health outcomes and to move beyond the ‘awareness’ of NCD risks towards implementation and evaluation in order to estimate program efficacy. Findings should be shared with colleagues both nationally and regionally in order to accelerate the establishment of best practices and to experience the development of PA programs in different settings. The Asia Pacific Physical Activity Network (APPAN) (Sydney School of Public Health, 2010) can serve as a communication vehicle for these matters.
Most programs were initiated and developed by the Ministry of Health as the lead agency. High-level government support has been shown to be an effective strategy for program feasibility (Englberger & Halavatau, et al., 1999; SPC & WPRO, 2007). Cross-sectoral partnerships with national public, private, non-governmental organisations, community groups and international agencies can contribute to program success and sustainability.
To address reported challenges, partnership collaboration is recommended in order to pool resources, expertise and scope opportunities for possible additional funding and training. Challenges relating to ongoing participant motivation, recruitment and retention were apparent across many programs, particularly in hard to reach populations, such as remote countries and remote outer islands within countries. Key decision makers could draw on ideas and experiences of others involved in program delivery and established evidence in this area in an effort to overcome this challenge. Social marketing of PA to participants was also reported as a challenge. Finally, barriers to PA relating to the physical environment can be addressed through environmental and policy modifications, such as improving infrastructure and safety for walking, led by cross-sectional government departments with the assistance of the private sector and community groups. Overall, drawing on international best practice for implementing PA programs in developing countries is advisable (WHO, 2008c, 2009b).
This stock take provides a snapshot of the increasing numbers, scope and reach of PA programs across the Pacific island countries and areas. PA professionals from the region, NCD key stakeholders and Public Health experts in and around PICs are advised to share ideas, best practices and evaluation methods in order to improve regional program efficacy and to learn from neighbouring countries. Governments of small island countries and communities outside the Pacific region are encouraged to similarly respond to WHO’s Global Strategy on Diet, Physical Activity and Health. Pacific programs that prove to be successful can be culturally adapted and implemented in other small island states. Cross-country comparisons can be used to identify global best practice and distribute programs further.
Cost-effective resources and innovative approaches are needed to halt or reverse the growing NCD epidemic in the Pacific region. Culturally appropriate policies and high-level political support, not only from the health ministry, but across government ministries of transport, education and municipality, can increase program reach. Current programs must be consistently monitored and evaluated in order to achieve measurable health improvements and to enhance program sustainability. More persistent and professional reporting of programs is required for effective monitoring and evaluation processes. The RE-AIM framework could serve as a tool for process evaluation and the STEPS survey for impact evaluation. It is recommended to harmonise monitoring and evaluation frameworks, processes and systems across the Pacific to facilitate cross-country comparisons.
NCD interventions at the individual and community level are as much recommended as environmental and policy approaches at the national and regional level. Wherever practical, PICs’ efforts to reduce NCD burden should be consistent with international and regional frameworks for NCD prevention and control.
Research on PA outcomes and, more broadly, on the effectiveness of NCD prevention interventions in the Pacific region is scarce. Objective four of the Western Pacific Action Plan for NCDs advises governments to promote research for the prevention and control of NCDs (WPRO, 2009). Continuous and sustained research should generate innovative and culturally appropriate NCD prevention programs which will assist in increasing population levels of PA to reduce the burden of disease in the Pacific region.