Role of policy makers in the implementation of successful physical activity in the Brazilian public health systemABSTRACT
Introduction: Understanding the role of local policymakers is an important pathway for analyzing physical activity as a public policy.
Objective: To analyze the role of health managers in implementing successful physical activity interventions linked to the Brazilian Unified Health System (Sistema Único de Saúde - SUS).
Method: Ten health secretaries, or representatives designated by them, from municipalities with interventions deemed successful across all regions of the country were interviewed. The interviews were guided by the question: how does local health management operate in the implementation of physical activity interventions within the SUS? The interview guide was based on the stages of the public policy cycle, and responses were analyzed qualitatively through deductive content analysis.
Results: Managers’ responses were superficial in the phases of problem identification, agenda setting, alternative formulation, and decision-making. However, in the implementation phase, managers reported supporting physical activity initiatives through partnerships, funding, professional incentives, and personal engagement. For evaluation, participant and professional reports were used to assess the success of the interventions.
Conclusion: Key aspects of planning public policies for physical activity were not addressed in depth by managers. Nevertheless, the efforts of managers, health professionals, and other stakeholders have created a successful track record in promoting physical activities within the SUS, despite the absence of overarching, structured public policies from the federal government.
Keywords:
Unified Health System; Health promotion; Population health management.
RESUMO
Introdução: Compreender a atuação dos gestores locais é um importante caminho para analisar a atividade física como política pública.
Objetivo: Analisar a atuação de gestores de saúde na implementação de intervenções exitosas de atividade física vinculadas ao Sistema Único de Saúde (SUS) no Brasil.
Método: Foram entrevistados dez secretários de saúde, ou representantes indicados por eles, de municípios com intervenções consideradas bem-sucedidas em todas as regiões do país. As entrevistas foram orientadas pela pergunta: como a gestão de saúde local atua na implementaçãode intervenções de atividade física no SUS? O roteiro de entrevista foi baseado nas etapas do ciclo de políticas públicas e os relatos foram analisados qualitativamente por meio de análise de conteúdo dedutiva.
Resultados: Os discursos dos gestores foram superficiais nas fases de identificação de problemas, formação de agenda, formulação de alternativas e tomada de decisão. No entanto, na fase de implementação, os gestores relataram apoiar as ações de atividade física por meio de parcerias, financiamento, incentivo aos profissionais e sensibilização pessoal. Para avaliação, os relatos dos participantes e dos profissionais foram utilizados para medir o êxito das intervenções.
Conclusão: Aspectos importantes do planejamento de políticas públicas de atividade física não foram abordados de forma aprofundada pelos gestores. No entanto, os esforços de gestores, profissionais de saúde e outros stakeholders permitiram a criação de um histórico de sucesso na promoção de atividades físicas no SUS, apesar da falta de macro políticas públicas estruturantes oriundas do governo federal.
Palavras-chave:
Sistema Único de Saúde; Promoção da saúde; Gestão da saúde da população.
Introduction
The current landscape of physical inactivity generates economic impacts on health systems, leading to costs associated with secondary and tertiary levels of healthcare due to conditions that could be prevented through an active lifestyle1. In this context, community-based interventions in public health are effective in reducing diseases and health-related conditions and should be adopted as public policy in countries2,3. International experiences report the successful implementation of physical activity interventions in public health4. However, despite their proven effectiveness, few studies highlight the role or perception of health managersin the implementation and sustainability processes of these initiatives5.
In Brazil, access to physical activity within public health is guaranteed by the law that established the Unified Health System (Sistema Único de Saúde - SUS). However, the country still lacks a consolidated and federally planned public policy to promote physical activity equitably nationwide. As a result, initiatives linked to the SUS have been implemented at the local level, under the responsibility of municipal health departments6. Despite recent efforts such as the Physical Activity Guide for the Brazilian Population7 and initiatives mentioned in this document-such as the Health in Schools Program, the Health Gym Program, and the Physical Activity Incentive Strategy.
With the aim of analyzing existing interventions, the Ministry of Health and the National Council for Scientific and Technological Development funded the Physical Activity Success Stories in Health project (Saúde a Partir de Atividades Físicas Exitosas - SAFE). SAFE considers a successful physical activity intervention to be one that increases participants’ physical activity through a planned, replicable, and sustainable process that ensures and promotes participation and autonomy8. Among the several areas investigated by SAFE, one of them was the management of physical activity provision as a public policy at the local level. This is crucial since political decisions (or their absence) regarding physical activity affect people’s and communities’ dignity, values, and life opportunities9.
It is important to note that the role of managers can influence the degree of implementation and the success of community-based physical activity interventions10. Therefore, we believe that understanding the role of local policymakers is an important path to analyze physical activity as a public policy. This understanding will help explain how and why interventions are successful and sustainable within local contexts11. The limited experience of lowand middle-income countries with successful public health physical activity interventions may contribute to the modest increase in population physical activity levels12. Thus, the objective of this study was to analyze the role of health managers in the implementation of successful physical activity interventions linked to the SUS.
Methods
This qualitative study is part of the research project titled Successful Physical Activity Strategies in Health - SAFE, which aims to evaluate physical activity initiatives within the SUS10. In the context of the SAFE project, an action is defined as a specific, targeted initiative, usually aimed at solving a problem or achieving a goal within a given context. The distinction between an action and a program lies in their scope and organizational nature. While an action is a specific and isolated measure, a program is a structured and continuous set of coordinated actions with mediumor long-term goals, defined targets, and allocated resources. In other words, a program may encompass several actions.
The project was approved by the Research Ethics Committee for Human Subjects at the Federal University of Santa Catarina under approval number 2.572.260, dated March 30, 2018, and CAAE 80431717.0.0000.0121. The SAFE project was funded by the National Council for Scientific and Technological Development and the Brazilian Ministry of Health.
Participants
Ten health secretaries (or representatives designated by them) from municipalities with physical activity interventions considered successful were invited to participate in the study. In Brazil, SUS management operates under a tripartite structure, with financial, executive, and legislative responsibilities shared among the federal government, states (26 states and the Federal District), and municipalities (n = 5,570) across five geographic regions (North, Northeast, Central-West, South, and Southeast). Each Brazilian municipality has a health secretary, appointed by the mayor-who is democratically elected by the population-and is responsible for SUS public policies at the local level. We understand the role of these managers as knowledge brokers, in line with Cranley et al.13, as their responsibilities include: promoting the use of research in decision-making; building networks and trust-based relationships; facilitating learning and knowledge exchange; establishing communication channels; assessing environmental needs; and managing knowledge, training, and exchange activities.
The 10 participating managers were selected based on the evaluation of 1,645 physical activity actions registered in the SAFE study. Of these, 85 were considered successful and were located in 43 municipalities. Ten of these municipalities were selected for on-site visits by the research team based on the following criteria: (1) two municipalities from each of Brazil’s five geographic regions (South, Southeast, Central-West, Northeast, and North); (2) for each region, one municipality had to be large, and the other medium or small. The aim was to ensure that the data collected would reflect the diversity of Brazilian contexts. After the ten visits, theoretical saturation was observed-i.e., little or no new information emerged from the interviews14- thus, no further data collection rounds were conducted.
Interviews
An interview guide was developed to address the following research question: How does local health management operate in successful physical activity interventions provided through SUS? The guide was structured around the stages of the public policy cycle, a well-established framework in the field of public administration. The public policy cycle is recommended by the World Health Organization for planning and analyzing health and physical activity policies15, and includes the following stages: problem identification, agenda setting, alternative formulation, decision-making, implementation, and evaluation.
Based on these stages, the interview guide was developed and its content validated by an expert in public administration. The final version of the questions, along with their corresponding objectives, is available in Supplementary Material 1.
The interviews were scheduled and conducted in person at the offices of the municipal health secretaries. At that time, the managers were informed of the evaluation results and that their municipality had been identified as having a successful action. The interviews lasted between 15 and 30 minutes, were audio recorded with participant consent, and conducted by the lead researcher of the present study (PFS). Interviews were carried out between August and November 2019.
Discourse Analysis
Interview data were analyzed using deductive content analysis16. This approach was chosen because a guiding concept had been defined prior to data collection- namely, answering the question: How does local health management operate in successful physical activity interventions provided through SUS? The analysis was conducted in three stages: preparation, organization, and reporting of results16.
In the preparation stage, interviews were audio recorded and manually transcribed. Transcripts were then sent to the respective managers for validation. Each transcript was stored in a Microsoft Word document and later imported into NVivo software version 12pro. In the organization stage, coding and categorization of the collected information were performed. Transcripts were reviewed, coded, and exemplified according to the stages of the public policy cycle. This process was carried out in pairs by researchers, and any disagreements in category allocation were discussed and resolved with input from a third reviewer.
The reporting of results is presented according to the stages of the public policy cycle. The grouping criterion was based on the similarity between the managers’ statements and the scope of each stage. To ensure anonymity, the managers were randomly ordered, and this sequence was used to identify the excerpts presented in the results.
Results
As shown in Table 1, of the 10 interviewed health managers, eight were women. Their professional backgrounds included administration (n = 2), nursing (n = 2), dentistry (n = 1), physical education (n = 1), physiotherapy (n = 1), mathematics (n = 1), medicine (n = 1), and social work (n = 1). Regarding their positions in the health system, the respondents included municipal health secretaries (n = 5), health program managers (n = 1), primary care managers (n = 1), health care directors (n = 1), and program coordinators (n = 2).
Characteristics of managers from municipalities with physical activity interventions considered successful.
Below, we present the managers’ reflections on their roles in implementing successful physical activity interventions, organized according to the stages of the public policy cycle.
Problem Identification
Managers reported interacting with sectors of the health system responsible for collecting and analyzing epidemiological data, although not specifically related to physical activity. Their statements did not indicate how such data informed decision-making for the implementation of successful physical activity interventions:
“(...) we also have a family health information management team. They monitor the indicators (...)” [manager 2]
“Today we have access to the Ministry of Health’s database, DataSUS” [manager 8]
Problem identification was based mainly on reports brought to the managers by the population or health professionals working in the field. According to the managers, issues were identified through informal conversations, such as:
“... through professionals who come and tell us: there’s a deficit in this area, we need to sit down (...)” [manager 4]
Previous experience working in the health system helped managers recognize problems related to the availability of physical activity services. Once in management positions, they felt better equipped to support interventions:
“... first of all, I believe that being a technical manager helps a lot (...) we end up knowing the population better, understanding the problems from the beginning to where they end-or at least to the point where we can develop some projects to address them, right?!” [manager 5]
Alternative Formulation
Only one manager described seeking alternatives to address the problem of offering physical activity. In this case, the manager highlighted the involvement of staff in developing a structured project:
“I asked a community health worker, with the support of the whole team, to write a project (...)” [manager 3]
Agenda Setting
Agenda setting was described in broad terms, with emphasis on the support of the broader management team. Managers referred to this team as including their peers, such as primary care coordinators or managers. One manager emphasized priority-setting in agenda discussions:
“... we sit down together and discuss which issue we’re going to prioritize. I’m always with my team. I’ve never made a decision alone.” [manager 4]
Decision-Making
The relationship between promoting physical activity and reducing healthcare costs was noted by some managers as a factor influencing their decision-making. However, this connection was based on qualitative perceptions rather than hard data:
“... the municipality understands that health promotion brings many benefits-not only in terms of people’s quality of life and improved health-but also in boosting self-esteem and reducing future costs.” [manager 2]
Implementation
Partnerships with the private sector, civil society organizations, and interand intra-sectoral entities were mentioned as key to supporting the implementation of successful physical activity interventions. For example:
“(...) we use chapels, sports courts, right? Often these are courts and spaces provided by the education department or by our local parish (...) We use those places, we also use public squares (...)” [manager 1]
Financial support was also cited as essential for implementation. However, managers highlighted the lack of incentives from state and federal governments. Most resources came from municipal budgets and were directed toward maintaining physical infrastructure, hiring professionals, and acquiring equipment:
“(...) what I can say here is that our work has been done with municipal public funds. We get almost no support from the state or federal government for this work here in the municipality. Physical education, dance, gymnastics, swimming, alternative therapies like acupuncture-all of these are paid for exclusively with city funds.” [manager 6]
Managers also mentioned personal efforts, often charitable and not formally linked to their institutional roles, to support implementation:
“(...) when social services visit with the social worker and say to me: [manager’s name], that person can’t afford sneakers! We pool our own money because if we go through the bureaucracy of using public funds, the year will pass and the sneakers won’t arrive. So what do we do? We buy them ourselves!” [manager 3]
Some managers referred to the institutionalization of public budgets specifically allocated to physical activity initiatives:
“There’s dedicated funding for this, a specific budget line, so the funds go directly to be used for that purpose. Sports have guaranteed funding. It’s not just ‘oh, if I feel like doing something, I’ll invest there.’ No, there’s a specific law. We even have targeted programs like ‘Exercise in the Square,’ backed by legislation.” [manager 6]
Evaluation
According to managers, evaluation was mostly based on feedback from the population and service professionals. Qualitative aspects were commonly highlighted, such as:
“What stands out to me most is the testimonials from people. When we visit the program sites, you can really see the response and the affection people have for the physical education professionals and the interaction they build.” [manager 2]
Managers acknowledged that evaluations were often carried out by frontline professionals rather than the local administration itself, indicating a degree of detachment from evaluation processes:
“(...) we have some professionals who conducted surveys with all their participants. So we do have some professionals and locations in the Health Gym Program that have done this quantitative and qualitative research. It’s very interesting... I can look up those surveys for you later.” [manager 2]
At least three managers reported using population health data as a basis for evaluation. For example:
“(...) I also brought this for you to see: we did a body mass index mapping here at the municipal level. In 2014, 66% of the population hada body mass index over 25, and today we can see that only 63.93% have a body mass index over 25... So there was a reduction at the municipal level due to all that mo-bilization.” [manager 9]
Organizational aspects, such as attendance and demand for program spots, were also used to evaluate success:
“It’s a service that yields great results-people participate, enjoy it, and especially show up. There’s a waiting list. For other activities we offer, no one shows up-the professional just sits there. But for physical activity programs, everywhere we implement them, they fill up.” [manager 6]
Discussion
This study aimed to analyze the role of health managers in the implementation of successful physical activity interventions within the SUS.
Difficulties were observed in planning physical activity as a public policy at the local management level, particularly regarding coordination with Primary Health Care management, even in municipalities where interventions were deemed successful. A lack of training and preparation of managers with respect to physical activity may negatively affect population access to these services9.
The problem identification stage-closely linked to understanding the territory and the context of the intervention17-was not thoroughly explored by the managers. In the context of physical activity, territorial specificities need to be integrated into the management and work process. In Brazil, health surveillance initiatives provide data on physical activity levels among the population, such as the National Health Survey and the Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey. Data from these sources should be used by managers to identify community needs and challenges18.
In the agenda-setting stage, the managers’ comments were superficial and suggested a lack of recognition of physical activity as a relevant policy issue. At the local level, this gap may hinder the inclusionof physical activity in municipal health plans, budgets, and professional work processes, including the implementation of protocols, guidelines, and care pathways. Aligning with national initiatives, such as the National Health Plan - which promotes physical activity - can support local decision-making and strengthen municipal agendas. Recently, Brazil launched the Physical Activity Guide for the Brazilian Population, which may also help structure local public agendas6.
Following agenda-setting, efforts are needed to define solutions through the alternative formulation stage. In this study, interviewees showed little engagement with this stage. A review of alternatives adopted by local governments to promote physical activity found that plans and programs were most commonly used19. Documents such as the Global Action Plan on Physical Activity 2018-20303, the Recommendations for Managers and Professionals based on the Physical Activity Guide for the Brazilian Population20, and the course Promotion of Physical Activity in Primary Health Care and Its Integration into SUS Planning and Management Tools, offered by the Open University of SUS, may serve as resources for guiding more effective local strategies. At a macro level, considering Brazil’s insufficient and unequal access to physical activity, special attention should be given to community-based interventions, which can serve as an entry point to health promotion and disease prevention services21.
In the decision-making phase, although discussed briefly, managers mentioned criteria such as healthcare cost reduction and improvements in quality of life and well-being. Cost-effectiveness analyses can encourage political engagement by supporting the prioritization of funding allocation for interventions that help reduce physical inactivity22. However, decision-making based on evidence was still limited-similar findings were reported in another study with managers from the state of Paraná23. This may be because evidence-based decision-making remains more prevalent in high-income countries24.
In the subsequent stages of the policy cycle-implementation and evaluation-managers’ statements were more detailed. It is worth reflecting that municipal public policies for physical activity investigated in this study appear to be largely designed by frontline professionals and supported by management during implementation. The lack of knowledge among local managers about the interventions may be related to the high turnover of health managers, which undermines continuity in public health efforts25. This frequent turnover could also contribute to the limited depth of the interview responses.
Regarding implementation, managers described several forms of support for physical activity interventions, such as partnerships with private, civil society, and interand intra-sectoral actors. These partnerships are important and strongly recommended for scaling up physical activity at the population level3.
Another form of managerial support was financial incentives to healthcare professionals involved in the interventions. Creating opportunities for training, continuing education, and capacity building can help strengthen physical activity promotion27. In general, professional qualification is necessary at all levels - including for managers. Including public health topics in professional education may lead to the development of more effective strategies28.
In the evaluation stage, most responses referred to non-structured assessments, based on community and professional feedback. The absence of structured evaluation using evidence-based tools limits the comparability, transferability, and assessment of true program effectiveness29. In the Brazilian context-marked by frequent changes in health leadership30-this becomes even more concerning, as anecdotal evaluation may fail to provide sufficient information for the continuity of interventions by incoming managers.
Organizational aspects of evaluation were rarely mentioned. A study on community-based physical activity programs in Brazil found that most evaluations focused on individual outcomes rather than assessing feasibility, sustainability, or implementation processes-dimensions more relevant to the organizational context31. Evaluations that consider both individual and organizational perspectives are essential to assess community-based health interventions31.
Some limitations of this study must be acknowledged. Variables such as length of time in office and managerial experience were not analyzed. Additionally, the role of municipal health management should not be reduced to the interview statements presented here, as many respondents likely no longer occupy their positions. These findings should be interpreted with caution, considering the complexity of public health management in lowand middle-income countries such as Brazil.
In conclusion, managers reported directing greater efforts toward the implementation stage, through partnerships, funding, professional incentives, and personal engagement. Some aspects of evaluation were also explored. Few elements were reported regarding problem identification, agenda-setting, alternative formulation, and decision-making. The results of this study suggest limited engagement by health managers with the planning of physical activity interventions as public policies. These findings reinforce the need to train managers to develop evidence-informed physical activity policies. Future research should explore effective strategies to improve managerial capacity in implementing community-based physical activity interventions.
Supplementary Material 1
Supplementary Material 1
Script based on the cycle of public policies used in interviews with health managers.
-
Funding
This study was funded by the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq) and the Brazilian Ministry of Health through the public call CNPq/MS/SCTIE/DECIT/ SAS/DAB/CGAN No. 13/2017.
Statement on the use of artificial intelligence tools in the writing process
However, chatGPT was used exclusively to assist in translating the article from Portuguese to English. All content was reviewed, adapted, and finalized by the authors.
Acknowledgments
We thank the Brazilian Federal Agency for Support and Evaluation of Graduate Education (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES) for the scholarships granted to the authors of this study, and the professionals who generously dedicated their valuable time to participate in the interviews that originated this research.
Data availability statement
The data are available upon request from the reviewers.
References
-
1 Ranasinghe PD, Pokhrel S, Anokye NK. Economics of physical activity in low-income and middleincome countries: a systematic review. BMJ Open. 2021;11:e037784. doi: https://doi.org/10.1136/bmjopen-2020-037784
» https://doi.org/10.1136/bmjopen-2020-037784 -
2 Simões EJ, Hallal PC, Siqueira FV, Schmaltz C, Menor D, Malta DC, et al. Effectiveness of a scaled up physical activity intervention in Brazil: A natural experiment. Prev Med. 2017;103S:S66-S72. doi: https://doi.org/10.1016/j.ypmed.2016.09.032
» https://doi.org/10.1016/j.ypmed.2016.09.032 - 3 World Health Organization, WHO. Global action plan on physical activity 2018-2030: more active people for a healthier world. Genebra; 2018.
-
4 Kim TY, Lee YS, Yu EJ, Kim MS, Yang SY, Hur YI, et al. Effects of a mobile healthcare service provided by public health centers on practicing of health behaviors and health risk factors. Nutr Res Pract. 2019;13(6):509-20. doi: https://doi.org/10.4162/nrp.2019.13.6.509
» https://doi.org/10.4162/nrp.2019.13.6.509 -
5 Furtado KS, Budd EL, Armstrong R, Pettman T, Reis R, Sung-Chan P, et al. A cross-country study of mis-implementation in public health practice. BMC Public Health. 2019;19(1):270. doi: https://doi.org/10.1186/s12889-019-6591-x
» https://doi.org/10.1186/s12889-019-6591-x -
6 Tenório MCM, Coelho-Ravagnani C, Umpierre D, Andrade DR, Autran R, Barros MVG, et al. Physical Activity Guidelines for the Brazilian Population: development and methods. J Phys Act Health. 2022;19(5):367-73. doi: https://doi.org/10.1123/jpah.2021-0756
» https://doi.org/10.1123/jpah.2021-0756 -
7 Umpierre D, Coelho-Ravagnani C, Tenório MC, Andrade DR, Autran R, Barros MVG, B, et al. Physical Activity Guidelines for the Brazilian Population: Recommendations Report. J Phys Act Health. 2022;19(5):374-81. doi: https://doi.org/10.1123/jpah.2021-0757
» https://doi.org/10.1123/jpah.2021-0757 -
8 Benedetti TRB, Rech CR, Sandreschi PF, Manta SW, Cruz DKA, Mendonça BCA. Best practices for physical activity in Primary Health Care settings: a concept elaboration study. Saúde e Pesq. 2020;3(3):503-13. doi: https://doi.org/10.17765/2176-9206.2020v13n3p503-513
» https://doi.org/10.17765/2176-9206.2020v13n3p503-513 -
9 Piggin J. What Is Physical Activity? A holistic definition for teachers, researchers and policy makers. Front Sports Act Living. 2020;2(72). doi: https://doi.org/10.3389/fspor.2020.00072
» https://doi.org/10.3389/fspor.2020.00072 -
10 Cooper J, Murphy J, Woods C, Van Nassau F, McGrath A, Callaghan D, et al. Barriers and facilitators to implementing community-based physical activity interventions: a qualitative systematic review. Int J Behav Nutr Phys Act. 2021;18(118). doi: https://doi.org/10.1186/s12966-021-01177-w
» https://doi.org/10.1186/s12966-021-01177-w -
11 Glasgow RE, Harden SM, Gaglio B, Rabin B, Smith ML, Porter GC, et al. RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review. Front Public Health. 2019;29(7):64. doi: https://doi.org/10.3389/fpubh.2019.00064
» https://doi.org/10.3389/fpubh.2019.00064 -
12 Pogrmilovic BK, O’Sullivan G, Milton K, Biddle SJH, Bauman A, Bull F, et al. A global systematic scoping review of studies analysing indicators, development, and content of national-level physical activity and sedentary behaviour policies. Int J Behav Nutr Phys Act. 2018;15(123). doi: https://doi.org/10.1186/s12966-018-0742-9
» https://doi.org/10.1186/s12966-018-0742-9 -
13 Cranley LA, Cummings GG, Profetto-McGrath J, Toth F, Estabrooks CA. Facilitation roles and characteristics associated with research use by healthcare professionals: a scoping review. BMJ Open. 2017;7(8):e014384. doi: https://doi.org/10.1136/bmjopen-2016-014384
» https://doi.org/10.1136/bmjopen-2016-014384 -
14 Curry LA, Nembhard IM, Bradley EH. Qualitative and mixed methods provide unique contributions to outcomes research. Circulation. 2009;119(10):1442-52. doi: https://doi.org/10.1161/circulationaha.107.742775
» https://doi.org/10.1161/circulationaha.107.742775 -
15 Pogrmilovic BK, O’Sullivan G, Milton K, Biddle SJH, Bauman A, Bellew W, et al. The development of the Comprehensive Analysis of Policy on Physical Activity (CAPPA) framework. Int J Behav Nutr Phys Act. 2019;16(60). doi: https://doi.org/10.1186/s12966-019-0822-5
» https://doi.org/10.1186/s12966-019-0822-5 -
16 Elo S, Kääriäinen M, Kanste O, Pölkki T, Utriainen K, Kyngäs H. Qualitative Content Analysis: a focus on trustworthiness. SAGE Open. 2014;4(1). doi: https://doi.org/10.1177/2158244014522633
» https://doi.org/10.1177/2158244014522633 -
17 Faria RM. The territorialization of primary health care in the Brazilian unified health system. Cien Saude Colet. 2020;25(11). doi: https://doi.org/10.1590/1413-812320202511.30662018
» https://doi.org/10.1590/1413-812320202511.30662018 -
18 Enes CC, Nucci LB. A Telephone Surveillance System for Noncommunicable DiseasesinBrazil.Public Health Rep. 2019;134(4):324-7. doi: https://doi.org/10.1177/0033354919848741
» https://doi.org/10.1177/0033354919848741 -
19 Racine NA, Hoye AV, Boyd A, Jackson F, Garbarino JM, Massiera B, et al. A scoping review of published research on local government policies promoting health-enhancing physical activity. Int J Sport Policy Politics. 2020;12(4):747-63. doi: https://doi.org/10.1080/19406940.2020.1816561
» https://doi.org/10.1080/19406940.2020.1816561 - 20 Brazil. Ministry of Health. Physical Activity Guidelines for Brazilian Population: recommendations for managers and health professionals. Brasilia; 2021.
-
21 Manta SW, Silva KS, Del Duca GF, Malheiros LEA, Malheiros M, Silva AF, et al. Physical activity clusters and income inequality in Brazilian adults. J Phys Act Health. 2020;17(9):859-66. doi: https://doi.org/10.1123/jpah.2019-0355
» https://doi.org/10.1123/jpah.2019-0355 -
22 Ding D, Kolbe-Alexander T, Nguyen B, Katzmarzyk PT, Pratt M, Lawson KD. The economic burden of physical inactivity: a systematic review and critical appraisal. Br J Sports Med. 2017;51(19):1392-1409. doi: https://doi.org/10.1136/bjsports-2016-097385
» https://doi.org/10.1136/bjsports-2016-097385 -
23 Becker LA, Rech CR, Hino AAF, Reis RS. Tomada de decisão baseada em evidências e promoção da atividade física entre secretários municipais de saúde. Rev Saude Publica. 2018;52(90). doi: https://doi.org/0.11606/S1518-8787.2018052000379
» https://doi.org/0.11606/S1518-8787.2018052000379 -
24 Brownson RC, Reis RS, Allen P, Duggan K, Fields R, Stamatakis KA, et al. Understanding administrative evidence-based practices: findings from a survey of local health department leaders. Am J Prev Med. 2014;46(1):49-57. doi: https://doi.org/10.1016/j.amepre.2013.08.013
» https://doi.org/10.1016/j.amepre.2013.08.013 -
25 Viana ALD, Bousquat A, Melo GA, Negri Filho A, Medina MG. Regionalization and Health Networks. Ciênc Saúde Colet. 2018;23(6):1791-98. doi: https://doi.org/10.1590/1413-81232018236.05502018
» https://doi.org/10.1590/1413-81232018236.05502018 -
26 Carvalho F, Almeida ER, Loch MR, Knuth AG. Body practices and physical activities in the tripartite management of the SUS: organizational structure, financing and supply. Ciênc Saúde Colet. 2022;27(6):2163-74. doi: https://doi.org/10.1590/1413-81232022276.15242021
» https://doi.org/10.1590/1413-81232022276.15242021 -
27 Barboni VGAV, Carvalho YM, Souza VH. Public health training in physical education curricula: a current portrait. Movimento. 2021;27:e27065. doi: https://doi.org/10.22456/1982-8918.113041
» https://doi.org/10.22456/1982-8918.113041 -
28 Tasca R, Massuda A, Carvalho WM, Buchweitz C, Harzheim E. Recommendations to strengthen primary health care in Brazil. Rev Panam Salud Publica. 2020;44:e4. doi: https://doi.org/10.26633/RPSP.2020.4
» https://doi.org/10.26633/RPSP.2020.4 -
29 Fynn JF, Hardeman W, Milton K, Murphy J, Jones A. A systematic review of the use and reporting of evaluation frameworks within evaluations of physical activity interventions. Int J Behav Nutr Phys Act. 2020;17(1):107. doi: https://doi.org/10.1186/s12966-020-01013-7
» https://doi.org/10.1186/s12966-020-01013-7 -
30 Silva AG, Prates EJS, Malta DC. Avaliação de programas comunitários de atividade física no Brasil: uma revisão de escopo. Cad Saúde Pública. 2021;37(5). doi: https://doi.org/10.1590/0102-311X00277820
» https://doi.org/10.1590/0102-311X00277820 - 31 Glasgow RE. Evaluation of theory-based interventions. In: Glanz K, Rimer BK, Viswanath K, editors. Health Behavior and Health Education: theory, research and practice. San Francisco: Jossey-Bass, 2002.
Edited by
-
Editor in Chief
Átila Alexandre Trapé https://orcid.org/0000-0001-6487-8160Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
-
Section editor
Inês Amanda Streit https://orcid.org/0000-0001-7962-8746Federal University of Amazonas, Manaus, Amazonas, Brazil
Reviewers’ assessment
The reviews of this article were originally conducted in Portuguese. This version has been translated using ChatGPT and subsequently reviewed by the Chief Editors.AuthorshipSCIMAGO INSTITUTIONS RANKINGSReviewer A
Format
-
Does the manuscript comply with the submission guidelines of the Revista Brasileira de Atividade Física & Saúde?
Yes.
-
Regarding formal aspects, is the manuscript well-structured, containing the sections: introduction, methods, results, and discussion (with the conclusion as part of the discussion)?
Yes.
-
Is the language appropriate, and is the text clear, precise, and objective?
Yes.
-
Was any indication of plagiarism observed in the manuscript?
No.
Comments:
-
No comments.
Abstract
-
Are the abstract and resumo appropriate (including objective, study participant information, variables studied, main results, and a conclusion), and do they reflect the manuscript content?
Yes.
Comments:
-
Replace policy makers with managers.
-
Line 6: Delete “participaram do 18 estudo”.
-
Last line: Regarding macro policies - the relationship between macro and micro (local) levels could be further explored.
Introduction
-
Was the research problem clearly stated and delimited?
Yes.
-
Is the research problem properly contextualized with respect to existing knowledge, progressing from general to specific?
Yes.
-
Are the reasons that justify the need for the study (including the authors’ assumptions) well established in the text?
Yes.
-
Are the references used to support the presentation of the research problem current and relevant?
Partially.
-
Was the objective clearly presented?
Yes.
Comments:
-
2nd paragraph, line 1: This seems like an assumption or a well-intentioned extrapolation. Consider clarifying or removing. Citing National Health Promotion Policy might be more appropriate.
-
2nd paragraph, line 3: Programs exist - consider citing Health at School Program, Health Academy Program and Physical Activity Incentive.
-
2nd paragraph, line 5: The citation seems out of context. Using “despite...” without referencing National Health Promotion Policy, Health at School, Program, Health Academy Program and Physical Activity Incentive feels awkward. Referring to these programs and the guide for managers makes more sense than the guide for the general public.
-
3rd paragraph, line 1: Which institution? Please clarify.
-
3rd paragraph, line 6: A success indicator is ensuring access, beyond just increasing physical activity levels (PAL). This should be better explained, especially given the lack of PAL surveillance at the municipal level.
-
4th paragraph, line 1: Use managers instead of leaders - it is more descriptive.
-
4th paragraph, line 3: Why use policy makers in English? Managers would be more appropriate.
-
4th paragraph, line 4: This is only partially accurate; there are additional factors that contribute to success.
-
4th paragraph, line 6: The statement is hard to support. Not all experiences are documented and evaluated. The cited article is a scoping review about scientific production, not actual field experience. Consider rephrasing based on the authors’ findings.
Methods
-
Are the methodological procedures generally appropriate for the research problem?
Partially.
-
Are the methods sufficiently detailed?
Partially.
-
Was the participant recruitment method appropriate for the study problem and described clearly and objectively?
Partially.
-
Are there details on the instruments used for data collection, including their psychometric properties and operational definitions of variables when relevant?
Partially.
-
Is the data analysis plan appropriate and well described?
Partially.
-
Were inclusion/exclusion criteria adequately described and appropriate?
Yes.
-
Did the authors provide information on ethical procedures followed?
Yes.
Comments:
-
Authors mention using NVIVO, but its role in the analysis is unclear. Categories were predefined, and it seems the researchers performed the analysis manually.
-
1st paragraph, line 2: Are these “actions and programs” or just “actions”? Remember that programs are not isolated actions.
-
1st paragraph, line 6: How do the authors classify the study? Qualitative and exploratory?
-
2nd paragraph, line 9 (Participants): Translate “policy makers as knowledge brokers” into Portuguese, e.g., mediators or knowledge translators.
-
3rd paragraph, line 1: Replace policy makers with managers.
-
3rd paragraph, line 2: Define what constitutes an action vs. a program.
-
4th paragraph, line 2: Were managers aware their municipality was selected for “successful actions”? How was this communicated?
-
6th paragraph, line 4: Indicate the interview period.
-
7th paragraph, line 2: Cite a source.
-
7th paragraph, line 3: Specify the concept.
-
8th paragraph, line 1: Indicate how the interviews were transcribed (manual, software, AI?).
-
9th paragraph, line 4: Was there a third evaluator or just the researcher pair? Please clarify.
Results
-
Are tables and figures used appropriately to support the findings?
Partially.
-
Are the number of illustrations in accordance with the journal guidelines?
Yes.
-
Is the number of participants at each stage and reasons for loss/refusal presented?
Partially.
-
Are participant characteristics presented and sufficient?
Yes.
-
Are the results appropriately presented, highlighting main findings and avoiding unnecessary repetition?
Yes.
Comments:
-
1st paragraph, line 1: Recommend including a table with manager number and characteristics (age, gender, education, position). This helps readers contextualize quotes without identifying individuals.
-
19th paragraph, line 1: Replace policy maker with manager.
Discussion
-
Are the main findings of the study presented?
Yes.
-
Are the strengths and limitations of the study discussed?
Yes.
-
Are results discussed in light of study limitations and existing knowledge?
Partially.
-
Do the authors discuss the potential contributions of the findings for scientific advancement, innovation, or real-world impact?
Yes.
Comments:
-
2nd paragraph, line 1: The number of citations is less important than the uniqueness of the reference.
-
2nd paragraph, line 4: Suggest discussing findings more than assigning causality. How could actions occur without planning? Consider discussing micro (local level) and macro (e.g., APS coordination) planning.
-
3rd paragraph, line 8: Emphasize the need for indicators beyond capital cities.
-
3rd & 4th paragraphs, lines 8 & 2: Replace policy makers with managers.
-
4th paragraph, line 6: Which initiatives, beyond the Guide, would be expected? Does PAS exist in these cases?
-
5th paragraph, line 8: Mention the UNASUS physical activity training for managers.
-
6th paragraph, line 7: Suggest citing Leonardo Becker’s study: https://www.scielo.br/j/rsp/a/qNTyp-7VfPY77RpHMhfK64Zj/?format=pdf⟨=p
-
9th paragraph, line 9: Translate advocacy as defense.
-
11th paragraph, line 7: Long-standing programs are often sustained by user testimonials. Examples: SOE, Academia Carioca, Mulheres em Movimento. The goal is not to replace qualitative with quantitative assessment, but to combine both.
-
13th paragraph, line 5: The issue is complex even in high-income countries like the US.
Conclusion
-
Is the conclusion appropriate and consistent with the study’s objective?
Partially.
-
Is the conclusion original?
Yes.
Comments:
-
14th paragraph, lines 1 and 10: Replace policy makers with managers.
References
-
Are the references up to date and sufficient?
Partially.
-
Are most references from original research articles?
Yes.
-
Do the references follow journal guidelines (quantity and format)?
Yes.
-
Are citations in the text appropriate and supportive of the statements made?
Yes.
Comments:
-
Additional references are suggested in the attached file and two more below:
-
Riquieri MRL, Carvalho ALB, Ouverney ALM, Sarti TD. Perfil dos secretários municipais de Saúde do Brasil: um panorama de três décadas. Rev Adm Pública. 2022;56(5):683-93. https://doi.org/10.1590/0034-761220220132
-
Ouverney ALM, Carvalho ALB, Machado NMS, Moreira MR, Ribeiro JM. Gestores municipais do Sistema Único de Saúde: perfil e perspectivas para o Ciclo de Gestão 2017-2020. Saúde Em Debate. 2019;43(spe7):75-91. https://doi.org/10.1590/0103-11042019S706
Comments to the Author
Dear Authors,
Wishing you bright days ahead!
Congratulations on the SAFE research and the resulting study.
-
This is a relevant article that addresses a topic needing further investigation.
-
I opted to insert comments directly in the text and attempted to offer reflections that could be better developed.
-
I emphasize that the recommendation for substantial revision, especially in the discussion, is due to the article’s potential to contribute significantly to the field.
-
I recommend highlighting the importance of guaranteeing access to physical activity as a success indicator. Before aiming to increase physical activity levels, ensuring access is a major step - particularly because the municipalities in question were considered successful for precisely ensuring access to part of the population. This is meaningful and deserves further exploration!
Decision:
-
Substantial revisions required.
- peer review recommendation: major-revision
Reviewers’ assessment
The reviews of this article were originally conducted in Portuguese. This version has been translated using ChatGPT and subsequently reviewed by the Chief Editors.AuthorshipSCIMAGO INSTITUTIONS RANKINGSReviewer B
Format
-
Does the manuscript comply with the submission guidelines of the Revista Brasileira de Atividade Física e Saúde?
Yes.
-
Is the manuscript well-structured, including the following sections: introduction, methods, results, and discussion (with the conclusion as part of the discussion)?
Yes.
-
Is the language appropriate, and is the text clear, precise, and objective?
Yes.
-
Was any indication of plagiarism observed in the manuscript?
No.
Comments:
-
The manuscript is well written and demonstrates that the authors have a solid understanding of the topic. The structure is coherent, enabling a fluid reading experience and facilitating comprehension of the points discussed. The results are presented clearly and objectively, contributing to the transparency of the conclusions. I recommend a grammar review, as some passages show issues with agreement.
Abstract
-
Are the abstract and resumo appropriate (including the objective, study participant information, studied variables, main results, and a conclusion), and do they reflect the manuscript content?
Yes.
Comments:
-
The abstract is appropriate and includes the suggested topics.
Introduction
-
Was the research problem clearly stated and delimited?
Partially.
-
Is the research problem properly contextualized with respect to the existing knowledge, progressing from general to specific?
Partially.
-
Are the reasons that justify the need for the study (including the authors’ assumptions) well established in the text?
Yes.
-
Are the references used to support the research problem current and relevant to the topic?
Yes.
-
Was the objective clearly presented?
Yes.
Comments:
-
The introduction is pleasant to read. However, it appears to lack some key information about the specific topic. Only the final paragraph addresses the study’s core theme. I suggest elaborating more on the role of managers in implementing physical activity initiatives within the Brazilian public health system, highlighting challenges, successful strategies, difficulties, barriers, or even gaps in the literature. Better addressing the research problem could strengthen the study’s relevance.
-
I would also like to highlight the sentence on line 17: “Despite recent initiatives such as the Physical Activity Guide for the Brazilian Population7,” which seems incomplete and needs to be clarified.
Methods
-
Are the methodological procedures generally appropriate for the research problem?
Yes.
-
Are the methods adopted for the study sufficiently detailed?
Yes.
-
Was the recruitment process for participants appropriate for the research problem and clearly described?
Yes.
-
Were details about the data collection instruments provided, including psychometric qualities (e.g., reliability, internal consistency, validity), and where relevant, operational definitions of variables?
Not applicable.
-
Is the data analysis plan appropriate and clearly described?
Yes.
-
Were the inclusion/exclusion criteria adequately described and appropriate for the study?
Yes.
-
Did the authors provide information about the ethical procedures followed?
Yes.
Comments:
-
The methodological procedures are coherent and clearly described.
Results
-
Are tables and figures used appropriately and do they support the results effectively?
Not applicable.
-
Is the number of illustrations consistent with the journal’s submission guidelines?
Not applicable.
-
Is the number of participants at each study stage, along with the reasons for any losses/refusals, presented in the manuscript?
Not applicable.
-
Are participant characteristics presented and sufficient?
Yes.
-
Are results presented appropriately, highlighting key findings and avoiding unnecessary repetition?
Yes.
Comments:
-
The presentation of results is well organized, facilitating the understanding of the study’s findings.
Discussion
-
Are the main findings of the study presented?
Yes.
-
Are the strengths and limitations of the study discussed?
Yes.
-
Are the results discussed considering the study’s limitations and existing knowledge?
Yes.
-
Do the authors discuss the potential contributions of the study’s findings to scientific development, innovation, or real-world application?
Yes.
Comments:
-
I suggest including more information in the discussion about the practical implications of the results for the work of managers implementing physical activity initiatives in the Brazilian public health system.
Conclusion
-
Was the study conclusion presented appropriately and consistent with the study’s objective?
Yes.
-
Is the conclusion original?
Yes.
Comments
-
The conclusion offers guidance for the role of managers in implementing physical activity in the public health system and highlights the importance of further research in this field.
References
-
Are the references up to date and sufficient?
Yes.
-
Are most references from original research articles?
Yes.
-
Do the references comply with the journal’s guidelines (format and quantity)?
Yes.
-
Are the in-text citations appropriate, i.e., do the statements cite references that truly support them?
Yes.
Comments:
-
The references are current and relevant to the topic.
Comments to the author
-
Congratulations on the work developed in this article. The writing is clear and the structure is well organized. The introduction addresses the proposed topic, although expanding on the research problem could further enrich the context. The results are clear and support the understanding of the study’s findings. The conclusion provides valuable guidance for future research and practical applications, demonstrating the relevance and applicability of the findings. I believe this work will benefit the field and the work of managers, especially considering the importance of the topic and the current lack of research in this area.
Decision
-
Accepted for publication in its current form.
- peer review recommendation: accept
