Description of health promotion actions in Brazilian cities that received funds to develop “ Academia da Saúde ” program

The objective of this study was to describe the health promotion actions that were planned in cities that received funds to develop the “Academia da Saúde” program. We conducted a phone survey with 914 Secretary of Health from cities that received funds until July/2012. We calculated prevalence (%) of health promotion actions, expected results, number of people that would be assisted, partners for actions, health professionals in actions, manager group for coordinate and main objectives for proposal the actions. The most of the cities were of the south (25.9%) and southeast (33.4%). The actions would provide reach over one million of people in 25% of the cities. Improves of physical activity and healthy food are priorities in the actions. The most of cities had partners for actions. Only 50% of the cities had used health indicators for planning the program and 25% of the cities had planned training for health professionals and manager group for coordinate the program. The actions had focus in physical activity and healthy food. A large of number of people would be reach in actions. Only half of cities used health indicators for plan and few cities planned professional training and manager group. It is necessary improve the use of health indicators for plan, training of professionals and developing manager group for coordinate the actions. The continuum evaluation these program to verify possible effectiveness results in physical activity level and healthy food of population is a challenge for the Ministry of Health.


INTRODUCTION
The Lalonde report published in the 70's showed that health promotion is the fundamental strategy for improving population's quality of life 1 .The physical activity practice and healthy food consumption are important actions for health promotion, but are variables difficult to change in population.Health education and health-friendly environments are important factors to help empower the population for action and to contribute for adoption healthy lifestyles 2 .
In Brazil, the National Health Promotion Policy was launched in 2006 3 along with the Health Promotion Network 4 .These policy and network were instrumental for the launch of the "Academia da Saúde" program 5 , that is a health promotion intervention with focus in healthy behaviors as physical activity and healthy food.This program is developed in primary health care settings and can provide facilities and trained staff 6 .
The physical activity practice in leisure time and the regular consumption of fruits and vegetables are low in the Brazilian population 7,8 .Community based interventions as "Academia da Saúde" may contribute for change this situation.
The "Academia da Saúde" began in 2011 and one of the principles is that the facilities implemented in primary health care unit can contribute for adopting physical activity practice and healthy food consumption because these units are the first access for health care in the public health system in Brazil.In 2012 over 2,000 municipalities had already obtained funding to implement the "Academia da Saúde" for health promotion actions in population.
However, the information about implementation of the actions, objectives, results expected, number of people that will be benefited, the partners, the participation of the health professionals and the evaluation process in "Academia da Saúde" are limited.Interventions based in behavioral change and applied in primary health care settings are promising for improve physical activity in populations 9 , but, details about the implementation actions are scarce and can contribute for better the planning process in health promotion.
Therefore, the aim of this study was to describe the health promotion actions that were planned in municipalities that received funds to develop the "Academia da Saúde" program until July of 2012.

METHODOLOGICAL PROCEDURES
We conducted a phone survey with 914 health managers (main responsible for health in cities) from cities that received funds to develop the "Academia da Saúde" until July of 2012 (44% of 2,074 cities that received funds).Details about this selection are describe in other paper 10 .This program was implemented by Brazilian Federal Government in 2011 with objective of contribute for improve physical activity, healthy food and others healthy behaviors in population 11 .Details about respondents are described in other paper 10 .Briefly, the majority were Secretary of Health (85.3%), had age of 39 years or under (55.4%) and were female (68.1%).
This survey was part the national implementation study of "Academia da Saúde" program.The questionnaire was elaborated by researchers of these study and was based on the principles of the National Health Promotion Policy and on the resolution creating the "Academia da Saúde" program 3,6 .The final version was composed by 68 questions divided in seven sections.Details about the questionnaire are described in Florindo et al. 10 .For this paper, we used information about sections 5, 6 and 7, which included the following information: section 5 (information about implementation of "Academia da Saúde" program); section 6 (expected results of "Academia da Saúde" program in cities); and section 7 (questions about new applications for funding the "Academia da Saúde" program).
The data collected was carried using Computer Assisted Telephone Interview and was conducted between August to December of 2012.
The prevalence of following responses was calculated: 1) health promotion actions; 2) expected results in short, medium and long term; 3) number of people that would be assisted; 3) partners for actions; 4) counterparts of the cities for funds of Federal Government; 5) health professionals for coordinate the actions; 6) training of health professionals for actions; 7) manager group for coordinate actions in the cities; and 8) main objectives for proposal the actions.All analyses were conducted in SPSS software version 15.0.
The study was approved by Ethical Committee of the Federal University of Pelotas, RS, Brazil (protocol number: 151.238) and the consent with health managers was obtained by telephone.

RESULTS
Most of the cities evaluated in this study were located in Southeastern region of Brazil (Figure 1).The Northeast region showed most difference in the comparison of total cities that received funds for develop the program and the cities that were evaluated in this study.
The main objectives for submission the projects were: 1) priority actions in the cities; 2) access for building the facilities for program; and 3) recruitment of professionals.However, public demand was also important (Figure 2).
Most cities planned to develop actions on physical activity promotion.The expected short term results were increases in the knowledge about physical activity and healthy food, whereas the expected long-term results were increases on the population levels of physical activity practice and healthy food consumption, as well as a decrease in the use of medications and medical consultations (Table 1).
Physical education professionals was the most cited category among those that would coordinate the programs' actions.However, only one- quarter of the cities had planned the training of health professionals for actions (Table 1).Most cities had supplemented the federal funding using their own resources as demanded by the contract with the federal government; and also built facilities for physical activity practice.Nonetheless, only half of the cities used health indicators for guiding the actions and only one quarter had a management group for the program.Finally, the majority of the cities had partners for implementing the actions, which were mainly from the public sector (Table 1).
About one-quarter of the cities had as aim to reach at least one million of people with health promotion actions (Figure 3).

DISCUSSION
This study showed that the priorities of proposals for "Academia da Saúde" program in Brazil were improve physical activity and healthy food.The main expected results are improve the knowledge (in short term) and increase of physical activity level and consumption of healthy food and decrease of medications and medical consultations (in long term).There are partners and counterparts for actions in the cities, but only half of the cities used health indicators or public management indicators for planning the programs, and only one quarter of the cities had planned training of health professionals and provided formation manager group for coordinate the actions.
The priorities established are important for public health, because physical inactivity and low consumption of fruits and vegetables are two important problems in world 12 and in the Brazilian population 7,8 .Physical activity practice and healthy food consumption are two priority actions for control of chronic diseases 3,13 and epidemiological surveys showed that these two positive behaviors are more prevalent in people of high socioeconomic level in Brazil 7,8 .Programs similar to "Academia da Saúde" can contribute for improve physical activity in leisure time 14 , and this behavior is associated with low consumption of medications 15 .
In addition, the education is a determinant factor of health in Brazil 16 and the education is related with healthy food and physical activity practice 7,8 .Therefore, actions for improve knowledge are important in health promotion.
Only half of the cities used health indicators or management tool for planning the actions.Although the goals were related with important public health variables for health promotion (physical activity and healthy food, for example), the use of health indicators for planning in the cities is very important for evaluate the program and can contribute for resolutions of municipal health problems 17 .These evaluation indicators can be based in principles of health promotion according with objective of "healthy cities" 18,19 .For example, one suggestion is improve the use of indicators of municipal health plan.Therefore, is recommended improve the evaluation this topic in next process of submissions the projects for obtain funds.
Most cities had partners for actions.The partnership are very important for health promotion actions, because for most of major public health problems is needed inter sectors actions 3,20 .For example, for interventions that aim to improve healthy life styles, partners of sectors as education, environment and sports are very important 21,22 .In case of the present study, the public sector was considered the more important partner.However, few cities had partners with Non-Governmental Organization, Universities and Class entities.We know that the Non-Governmental Organization 23,24 and Class Entities 25 can contribute with many actions in public health.In this case, we recommended that will be improved the partnership with other sectors outside of governmental context.
Physical education professionals were considered as main responsible for coordinating the actions in cities.But, other health professionals also were cited and are important.For example, Florindo et al. 10 showed that nutritionists and physical education professionals are very important for promotion healthy food and physical activity in these cities with "Academia da Saúde" 10 .And survey conducted in primary health care settings in Brazil showed that physicians and nurses are important for physical activity promotion 26 .However, is necessary improve actions for training these professionals.Only 25% of the cities had plan for training health professionals for develop the actions in "Academia da Saúde".Studies conducted with health professionals in Brazil showed that knowledge is important for physical activity and healthy food promotion in primary health care units 26,27 .The food guide for Brazilian population and book about physical activity promotion in primary health care settings can be good instruments for training these professionals 28,29 .Only half of the cities had planned the actions with basis in health indicators or public management.This result is worrying, because is related with the justification of the program in the cities and extensive evaluation of the actions.The use of health indicators or public management for planning of actions could contribute for resolutions public health problems in the cities.In this case, the suggestion is that the actions can be planned with basis in epidemiological indicators or in primary health care indicators.For example, cities can use data of National Health Surveys or data of Ministry of Health.
It is important clarify that the actions studied in this paper were planned to be conducted in these cities, but we not know if actions are implemented in this moment.And is need to encourage the use of health indicators for plan of the actions in cities and improve the evaluation process of the programs.For example, systematic review showed that physical activity interventions with focus in behavior and social approach involving multicomponent strategies, social support in community, physical activity counseling in primary health care and community physical activity classes are important for increase of physical activity 9 .Therefore, we recommend that the cities include others variables for evaluation program as number of people that participated of actions and received intervention (for example: number of people that participated of the groups, number of people that adhered and number of individual counseling).In addition, we suggest include others aspects of health promotion in evaluation as equity, social participation, inter sectors actions and use of quantitative and qualitative methods 18 .
In most cities will be offered counterpart for funds that were received of Federal Government and the facilities that the cities are building are related with physical activity or nutrition interventions (for example: multiuse space for gymnastic and stretching, living space, bathrooms, space for equipment or material warehouse).The facilities are very important for that the cities can achieving your expected results, as for example, the increase of physical activity level, because the built environment for physical activity practice are related with physical activity level [21][22] .In addition, interventions of health promotion also should contribute for modify the environment for facilitate the change behavior and for contribute with empowerment of people 2,21,22 .
Few cities had manager group for coordinate the program.This is worrying, because the manager group is important for the empowerment and social control of the health promotion actions and sustainability of the program 2,20 .Furthermore, the manager group is essential in health promotion process 18,19 .The formulation and proposal of manager groups needs to increase in cities with "Academia da Saúde".
The "Academia da Saúde" program is very promising as intervention of health promotion, because the number estimate of people that will be served for actions is exceed one million of people in the at least 25% of the cities.Many people can be benefited with these actions in primary health care settings, because the Unified Health Care System has a good coverage for Brazilian population 30 .
This study has some limitations.Firstly, is important mention that responses of health managers can have reflected some opinions about what they really would like in terms of the actions, but, not the actions that really are being carried in the cities.In this case, new evaluation process are necessary to verify if the actions are being conducted.Another limitation is the sample size of the cities and the distribution of these cities in Brazil, because we had a low response rate (44%), and half of the cities were the south and southeast and a few cities were of north and midwest (18.7%).However, excluding the northeast region, the differences between the cities of regions that received funds and cities of regions that were evaluated in this study not were large.
We conclude that the actions proposed by cities that received funds for develop "Academia da Saúde" program are based in physical activity and healthy food promotion, the most of the cities have partners showing inter sectors actions, but is need improve the use of health indicators for evaluation process and planning health professionals training and induce the formation of manager group for coordinate the program in the cities.Furthermore, the continuum process of evaluation these actions to verify the implementation in the cities and mainly the evaluation of effectiveness in physical activity level and healthy food consumption of the population in the cities that received funds is a big challenge for the Ministry of Health.

Figure 1 .
Figure 1.Prevalence (%) of cities that received funds for "Academia da Saúde" program until July of 2012 (n=2074 cities) and cities that were evaluated in this study (n=914 cities), according region in Brazil

Figure 2 .Figure 3 .
Figure 2. Main objectives for submission of the proposals in the cities

Table 1 .
Characteristics of plan for "Academia da Saúde" program in 914 Brazilian cities that received funds until July of 2012.
*Health managers could answers more than one alternative