Physical activity awareness campaign in Mbarara Municipality

Original Editor -Atwongyeire Night as an assignment for the Physical Actvitiy course

Top Contributors - Wendy Walker and Amanda Ager  

Abstract

Time for waiting to treat and rehabilitate is gone, now prevention is the goal. Prevention is always better than cure. As concerned citizens of Uganda, we should not apportion blame for the increased cases of NCDs to either government or community. Collective efforts of government, Civil Society Organizations, communities, individuals, private sector in promoting interventions geared towards reducing NCD risk factors is the shorter route to the reduction of increased cases of NCDs in Uganda.


There is insufficient knowledge on the dangers and the risk physical inactivity poses to health in our communities. The fact that the number of people living with NCDs is not known makes the situation more worrying.


Physical activity has significant health benefits and contributes to the prevention of non-communicable diseases [collaborating for health, 2012].
Physical inactivity is the 4th leading risk factor for poor health worldwide and it is considered a modifiable risk factor for non-communicable diseases and death [WHO, 2016]. The rise in the prevalence of non- communicable diseases and level of physical inactivity in Uganda is worrying [Prof Wabwire, 2011].


Opportunities to prevent and control NCDs occur at multiple stages of life; interventions in early life often offer the best chance for primary prevention [Common Wealth Health Partnerships, 2014].


People and communities should be empowered and involved in activities for prevention and control of NCDs, including advocacy, policy, planning, legislation, service provision, monitoring, research and evaluation [WHO Global NCD action plan2013-2020]. This campaign is aimed at creating awareness and educating the community on the benefits of physical activity in the prevention and control of non-communicable diseases, and the dangers of physical inactivity and sedentary behaviours on general health. The campaign will run through schools, Mbarara regional referral hospital, Mbarara University of science and Technology, Bishop Stuart University Mbarara, and the general Mbarara municipality community. The first steps in the reduction of NCDs require individuals to take care of their health by avoiding life styles leading to NCDs – It’s everyone’s responsibility to fight NCDs.

Introduction

According to the global recommendations, it should be recognized that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being, without distinction of race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or other status as enshrined in the universal declaration of human rights. (WHO Global NCD action plan2013-2020) [This is a great example of referencing!]. People living in Mbarara Municipality and Uganda in general have a right to good health and care, through prevention of disease and proper management. This cannot be achieved without the education and awareness of the effects of PA on their health. Treatment of the whole individual not necessarily the disease is what is needed in my community.


Mbarara municipality is a developing town and soon to be given city status, many people in the community are advancing economically and the life style is shifting to a modernized kind of life, with more work done in sitting; this includes too much TV viewing at home, computer use by bank workers, office men and women, students and teachers/lecturers, long sitting by taxi drivers, motorbike cyclists, to mention but a few. Cars and motor bikes are the leading mode of transport, as people get busier/ richer, there is no time for anyone to walk or exercise. Walking and cycling as modes of transport for school going children and people moving to work is slowly and steadily diminishing. Road safety is compromised especially for the school children and without a doubt walking is very difficult and is looked at as a mode of transport for the poor.


The numbers of patients attending diabetic, hypertensive, cancer and respiratory clinics at Mbarara Regional Referral Hospital have continuously increased over the years [ Health management systems, Ministry of Health]. Very many patients present late for treatment and rehabilitation, very limited opportunities for regular check-ups due the overwhelming numbers of patients and few health workers, and this shows more need for primary health care policies to be put in place.


Uganda still lacks an operational Policy, strategy or action plan to reduce physical inactivity and or promote physical activity, and there is no operational policy to reduce unhealthy diet and or promote health diets and, lacks evidence based national guidelines, protocols, and standards for the management of major NCDs through primary health care approach (World health organization, non-communicable diseases (NCDs) country profiles, 2014).


The ministry of education and sports has put Physical Education as a mandatory subject to be taught in all primary and lower secondary school, but unfortunately, many schools in Uganda are concentrating on pursuing academic Excellency at the expense of physical education. This is against the 2008 ministry of Education and Sports guidelines for improving the conduct of physical education and sports in institutions, which require each educational institution to include PE as a subject on its formal class timetable (Nangonzi & Joseph Kimbowa 2013)[good]. Youth in higher secondary school and universities/tertiary institutions remain with no chance of being physically active and this affects girls more than boys.

Community Intervention Description

Mbarara Regional referral Hospital is a general and public hospital that employs all members of the multi-disciplinary team [www.health.go.ug]. The hospital runs various clinics in hypertension, diabetes, oncology, respiratory diseases and mental health. This is a good community through which physical activity (PA) messages can be properly and professionally transmitted to the patients. Adequate education of PA benefits in the management of NCDs and prevention of co-morbidities to the entire medical fraternity will increase participation, involvement in and referral for physical activity.
The two universities, Mbarara university and Bishop Stuart university will be involved in the campaign as areas with community and public health departments that will be used to transfer information to the various communities they engage in clinical practice and placements.
This community intervention case study will be operated on the strategies including;

Public education to raise awareness on prevention and treatment of NCDs by physical activity.

The use of mass media and other forms of communication provide an effective way to transmit consistent and clear messages about physical activity to large populations [prof Fiona Bull, 2011]. In Uganda, physical activity promotion is absent from mass media. Using various forms of media can be used to raise awareness, increase knowledge, shift community norms and values and motivate the population to be more physically active. Public education will include print, audio, use of social media, posters, and public relations, mass participation events like organized walks, runs or marathons, mass distribution of information as well as other uses of internet. This will aim to build health literacy and break several barriers to good health like limited time, poor environment, lack of skill, among others, leading to physical inactivity.

Physical activity and NCD prevention integrated into primary health care programs.

Doctors and health care professionals are important influencers of patient behaviour and key initiators of NCD prevention actions within the health care system and can influence large proportions of the population (Br J Sports Med, 2012). Mbarara University of science and technology has a community program for all students doing medical courses including medicine, physiotherapy, laboratory science, and many others. The program is currently engaging forty different communities in south-western region and works on treatment of patients, screening of the patients and referral for specialized treatment. The plan is to include the component of physical activity into the community placement for students through which the program managers and the students learn and transfer knowledge of PA to the various communities, PA component will be championed by the physiotherapy students. Another channel that has been identified is through the department of public health, Bishop Stuart University. The department trains various health workers in the field of public health with already existing community outreach clinics. They have a sports scientist on the team and the students, and educators are a good team to work with in ensuring PA is integrated into both primary and secondary prevention of NCDs. Including physical activity as an explicit element of regular behavioural risk factor screening for NCD prevention, patient education and referral is the main aim for this campaign. Promoting PA in Mbarara will require additional training of health professionals to build competencies in NCD prevention through behavioural risk factor modification and physical activity. The plan is to involve all the members of the community health team in creating awareness on the importance of preventing all diseases, but mainly NCDs through physical activity. Educating people (patients and caregivers) attending the out-patients clinic, the antenatal clinics and other specialized clinics in Mbarara regional referral hospital is a way to convey positive messages on Physical activity to people who already have NCDs or do not have, going to Hospital with other conditions.. The talks will focus on the dangers of physical inactivity in relation to health and awareness on breaking barriers to PA. The talk will be delivered to all patients waiting to be reviewed by doctors and other clinicians. The pregnant women will be taught the types of exercises that are safe to do when pregnant like walking, cycling, swimming or dancing, and the exercises to be continued or added after delivery. During this time, education on how to progress their activity levels and teaching them to help their children become active during the preschool period will be done. Patients attending the specialized clinics like diabetes, hypertension and cardiorespiratory will be taught the necessity of becoming physically active as a method of treatment, secondary prevention and prevention of co-morbidities.

Reviving physical education in primary and secondary schools.

This is aimed at getting the school population aware of the impact of exercise/PA, making sure that physical education is beneficial for neurodevelopment of the young children. Using PE as a strategy for primary prevention of disease and primary health care will trigger more efforts by the policy makers and school administrators to give more importance. The recent evidence indicates that adding time to the school day for PE programs does not decrease academic performance and may contribute to improved academic outcome. Implementation of the reviving PE will need to review policies, curricula, or teaching practices, also to identify why the current policy on PE has not been very effective.

Training of teachers in PA from various schools and provision of space and equipment for use during PE lesions/Classes. Involvement of the public health professionals can provide PE teachers and coordinators with resources, tools, and strategies to build advocacy and promotion plans for quality physical education.

The key strategy is to use games, activities like dancing, competitive sports that encourage youth to enjoy physical activity that is moderate to vigorous intensity. These strategies are implemented within physical education (PE) classes, but also can be applied in different youth oriented settings, such as community and recreation centres and, after-school programs including holiday time.


If schools embrace the reviving of PE, students’ flexibility, muscular endurance, physical activity related knowledge, and overall physical fitness are likely to improve. School-based PE also provides students the opportunity to learn skills such as self-assessment, self-management, and goal setting for physical activity that can lead to a physically active lifestyle and a generation that is keen on primary prevention of NCDs.

It is important to have advocates for PE at every level of the education system in Uganda. There is need to get many people involved to help with the ongoing development, monitoring, and sustainability of the school-based PE program. The plan is to have a diverse group that includes physical educators, health educators, food service staff, parents, community members, school administrators, school counsellors, nurses, and students. All stake holders when identified and educated, the strategy will work better with the enforcers having a clear understanding of the need of the program.

Individual lifestyle change initiatives.

This approach uses strategies that are tailored to an individual’s specific interests, preferences, and readiness for change. It will be used for people who are high risk and those with limited motivation to PA and exercise. It will include some patients attending the cardiorespiratory, hypertensive and diabetes clinics at Mbarara regional referral hospital, also including the patients coming for the physiotherapy individual treatment with the message of physical activity, focusing on their current activity levels, physical condition, other chronic illnesses and screening for the risk of future NCDs, pregnant women and patients with mental disorders. This strategy is intended to teach behavioral skills to help participants incorporate physical activity into their daily routines, including building support for new behavioral patterns by creating social support networks or using existing social networks, reinforcing behavior through self-reward and positive self-talk, problem-solving geared to maintenance of the behavior change, and preventing relapse into sedentary behaviors. This intervention strategy will include motivational interviewing, helping people create time in their tight schedules and also giving them the skills through health and fitness settings. Assessment of the home/work environment and identifying barriers specific to the individual(s) will be another element for this strategy, and helping them to suit their environments into their PA needs likely to minimize the risk of relapsing.

When properly understood this intervention will play a good role in community programs and these individuals can work as advocates for the community-based physical activity classes in work sites, schools, and homes. Increasing physical activity requires focusing on several sectors of the community and individual lifestyle change is a major component in community interventions. These programs are likely to complement and enhance the effects of policy and environmental interventions, especially where communities, health care organizations, and other key sector have a role to play in creating environments and policies that support physical activity and other individual behavior changes. This can support sustainability of individual behavior changes, and the general community programs.

Community-wide programs

This is aimed at creating awareness to the general community about the benefits of Physical activity as a preventive measure for NCDs. As part of primary prevention, community wide campaigns will also target on screening for indicators of physical inactivity like growing industrialization, increased sitting periods/professions, reduced levels of active transport, gaining excessive weight, very busy schedules, to mention a few. Emphasis to be put on the need for regular check-ups to determine current health status, and the importance of Physical activity in health and disease. Using key settings, such as cities, local governments, schools and workplaces provides the opportunity to integrate policies, programs and public education aimed at encouraging physical activity. In this case, prevention will focus on educating and motivating people to help them increase their physical activity. Communitywide campaigns will address different groups including individuals, institutions and schools, and local community gatherings. These community programs will be designed to promote and eliminate barriers to physical activity and general health of community members. The public health department in Bishop Stuart University has a community based program for the students pursuing their diploma, bachelors programs. I have contacted the head of department of that unit and he positively picked interest in physical activity as another element of their program. They are already sending messages about PA, but they realize there is more input needed.  This strategy is likely to increase the numbers of people starting physical activity programs and more people will be aware of how important PA is to their health.  This will equip more people and familiarize them with the simple routine of PA like brisk walking or cycling that can be done at home or while moving to work/school.  The plan is to seek approval from the managers of various organizations for these campaigns to be effectively carried out and accepted. I have already discussed with administrators of several institutions and schools, and they are working on their schedules to find time for me to educate their employees and students.

Participation in sports

Spectating in sports is now the order of the day in many communities in Uganda. Many people young and old living in Mbarara municipality enjoy and spend a lot of time watching and listening to both local and international sports. Encouraging all sports fans to participate actively in various sports activities using the same platforms can make a big impact. Spreading positive messages on the importance of active participation in sports is a sure way to create awareness of the dangers of physical inactivity among sports fans. Sport is popular worldwide and increased participation in physical activity can be encouraged through implementation of community sport or ‘Sport for All’ policy and programs. Whereas providing enjoyable physical activity for everyone is a difficult journey to tread on, using the available government and school play grounds can be adopted to increase communities’ involvement in sports. Using these facilities, the adaption of sports to provide a range of activities to match the interests of men and women, girls and boys of all ages, in addition to well-coordinated coaching and training opportunities can be implemented. Calling on board all the sports club leaders and coaches is an explicit priority of sports program strategy. Implementation will involve partnerships between the media promoters of sports, the sports clubs in the community and the sports coaches or trainers in various universities and institutions of learning, sporting organizations along with community-based clubs and other sports providers. Organizations can promote physical activity through supportive policies and programs that reduce social and financial barriers to access and participation, and increase motivation to be involved, including individuals with mental or physical disabilities. There are already existing organizations that organize a few sports events, taking advantage of such publicity to create awareness on PA benefits can give people more motivation to participate in these sports activities. Education of the community on the fact that physical inactivity and sedentary behaviour is a silent killer will awaken more people from their sleep of business as usual. Sport participation and PA have a key role in the primary prevention of many chronic illnesses including cardiovascular diseases, type 2 diabetes, cancer, hypertension, obesity, depression and osteoporosis.

Social support groups in community settings

There are no existing social groups for behaviour change in physical activity, but there are several support groups in various communities that involve money saving, family development, health education and sometimes they perform activities together like simple exercises, dancing. Members of such groups usually develop in various aspects of life and giving them a good lesson on physical activity could be a starting step to get people supporting each other in the same. Most of these groups are for women and considering the fact that women are less active that men, this is an opportunity to boast women’s levels and prevent relapse. These social groups already help women develop health diets for their families, and everyone in the group struggles to improve being inspired by other members. Using the same groups to teach members the magnitude of the dangers of live inactive lifestyle will motivate people to live healthy by becoming physically active. This will include urging members to complete specified levels of physical activity, or setting up walking or other groups to provide companionship, friendship, and support while being physically active. Getting social support groups involved may improve many other strategies because they provide ways for participants to identify barriers to physical activity and come up with solutions .Participants will be connected with familiar participants and physical fitness centres to monitor progress and encourage continuation of activities

Creation of places for physical activity and recreational centres.

This intervention strategy will involve building of exercise facilities, or access to existing nearby facilities. Having access to places and opportunities for physical activity and knowing these opportunities exist is critical. These facilities will be equipped with clear information and contact person for educating people on the benefits of exercise, screen for risk factors and or contraindications and they will be an important component in the implementation of this community intervention. It will aim to target individuals or groups of people who need motivation and skill to start being physically active. Some People may have the necessary knowledge, skills, attitudes, and motivation to be physically active, but if they do not have access to the necessary opportunities, they may be restricted or prohibited from being active. Discussing with many of my contacts, there is realization that many people would exercise more if facilities were easily accessible, though time constraints remain the biggest challenge to exercise. However, with community support and involvement, increased access to physical activity opportunities is more likely to result in increased use. Many free and affordable facilities have been identified in Mbarara municipality that could best be put to use for physical activity. There are several open grounds, gyms and recreation centres that have no attendances on many days, mainly due to lack of publicity or the fact that people don’t appreciate the availability of such facilities. Plans are also underway for Mbarara University to build a gym for the students and staff, Bishop Stuart University community already has aerobic classes going on, and these are areas where people can be referred to for continued exercise.

Active transport through walking and cycling

‘Active transport’ is the most practical and sustainable way to increase physical activity on a daily basis ( Br J Sports Med, 2012), walking and cycling to and from work or school is an easy way to be physically active at no cost. In my community, policies related to road safety and environmental change are very complicated matters, and advocating for change in such areas does not come easy. For this strategy at this time, focus will be put on encouraging adults to walk to work, and walk with their children to school if possible to avoid road traffic. Educating communities, workplace gatherings and general public education through media about the how lifestyle can be made simply by walking, will change a lot. People were originally very good at walking for transport, and very many people still walk a lot here, but they walk very slowly that they may not have health benefits from just walking. There is need to motivate people who are walking that it does not show lack of money to walk, but rather that they do it proudly to improve and maintain good health. Educating non-walkers that walking has enormous benefits will attract more communities to do more active transport. Young people and older men enjoy cycling and this can be improved by encouraging others including women to start cycling. There will be education for women on the importance of cycling and efforts to break the cultural norms and values. This can be implemented by teaching young girls in schools and showing the community that cycling has no danger of loss of dignity for the women. Making cycling competitive and adopting it as a means of transport makes travel fast, affordable and active. Increasing active transport requires the development and implementation of policies influencing land use and access to footpaths and bikeways, in combination with effective promotional programs to encourage and support walking and cycling for travel. While advocating for policies that support active transport, encouraging communities and individuals to start walking and cycling safely is a good starting point.

Implementation and Outcome

Two local radio stations have already been engaged and plan is underway to start running PA education talks during health and sports shows. The plan is to combine approaches that are socially accepted and supported by the community. Combining these with the existent community-based programs and events that are well sponsored will help with sustainability. This might prompt people to get more active or even ask more questions.
The inspector of all primary and secondary schools has been contacted and she welcomed the idea, she plans to contact the inspector in charge of physical education, then educating the team on the necessity of physical activity through PE. Some school administrators have also been identified and contacted some of whom are members of the board that makes policies and regulations governing schools. This will definitely take time, but it is a positive way to carry out comprehensive education for children, youth, teachers and parents of the children attending those schools. This intervention will be evaluated when policies are well coordinated and monitored in schools. There is great need for follow-up by the several stakeholders to sustain the revived PE policies and programs.


Contacting the facility managers for the various government facilities, discussing with the various ministries of government including the municipal health inspector and the district health officers will be some of the ways in which this intervention case study will be implemented.


Conducting interviews on awareness of the benefits physical activity or using the barriers to health quiz will be the tools used to evaluate the outcome of the campaign. These will be conducted among the individuals, the communities, schools and workplaces where the campaign will be run. Students, teachers and parents will be considered for participation, the participants in sports and the social groups will be randomly chosen.

Discussion

The questions for this intervention have been raised even just at the planning level and the lessons learned include;
There is need to have facts at hand and great confidence when explaining something that people seem to know much about, and challenging them with the recent evidence. People in my community are relaxed and sometimes they avoid the facts and prefer to ignore than realize the problem and find the solution.


Having great a great passion for physical activity has helped me to identify the critical areas where things must change, making people come to terms with the fact that life is changing and lifestyle has to change as well.


The attitude of policy makers and big stake holders towards physical activity is still poor especially when they imagine that people should know what to do. This complicates the implementation of this intervention, but giving up is not an option at this moment.


Physical activity is a virgin land to explore and the exploration has kicked off. There is great need for research on the patterns and trends of physical activity among health workers, and their ability to prescribe physical activity for their patients and communities. This will work as an eye opener to many health professionals.


Very challenging to penetrate existing systems with good ideas, or wanting to do what is not being done, it brings conflict of interests. So starting slowly and identifying benefiting partners is a better option.

References


  • WHO: Global action plan for the prevention and control of non-communicable diseases 2013-2020.
  • Nangonzi & Joseph Kimbowa, 2013: Physical education in Uganda. Nserek Ibrahim, 2014: Non- Communicable Disease on the rise in Uganda; who is to blame.
  • World health organization NCD country profiles, 2014.
  • Global Advocacy for Physical Activity(GAPA) the Advocacy Council of the international Society for Physical Activity and Health(ISPAH), NCD prevention: Investments that work for physical activity. Br J Sports Med 2012; 46:8; 709-712.
  • Centres for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: The CDC guide to strategies to increase physical activity in the community. Atlanta: U.S. Department of Health and Human Services; 2011.
  • Health management information systems; Ministry of health resource centre, ministry publications; accessed from www.health.go.ug>hmis.
  • Mbarara Regional Referral hospital; Ministry of health: accessed from www.health.go.ug.
  • Parliamentary forum on Non communicable diseases,2011
  • Fiona Bull, 2011: Global Advocacy for physical activity; 7 investments that work for physical activity.
  • Collaborating for Health, 2012; the Benefits for Health and wellbeing, 2nd Edition.
  • WHO, 2016;Global Recommendations on Physical Activity for Health.
  • Commonwealth Health partnerships,2014; A life-course approach to NCDs.