Preventing chronic diseases through physical activity in the Pacific Islands. A workplace health promotion programme in Vanuatu
“It’s an emergency!” delegates declared in 2011 at the Pacific Island Forum in Fiji, convened by the Secretariat of the Pacific Community and the World Health Organization Office of the South Pacific. The emergency referred to the ever-increasing burden of non-communicable diseases (NCDs) in the Pacific Islands. The Pacific region is experiencing among the highest prevalence of NCD risk factors in the world. American Samoa, Tokelau and Nauru have overweight and obesity rates of 93.5%,7 86.2%,8 and 82.2%9 and diabetes rates are 47.3% in American Samoa, 33.6% in Tokelau, and 32.1% in Micronesia. A total of 70% of the global increase in diabetes is expected to occur in the Asia Pacific region. The Pacific Island countries and areas are predicted to experience among the greatest increases in diabetes prevalence worldwide.
Urbanisation, westernisation, and rapid changes in food supply and security have contributed to obesogenic environments in the PICs. These environments support poor diets and high levels of physical inactivity. Supporting the good health of Pacific populations by encouraging and facilitating the adoption of healthier lifestyles is therefore of utmost importance. This doctoral work is the first in the specific area of physical activity health promotion in the Pacific Islands that seeks to understand and increase PA levels and reduce NCD risk.
The thesis consists of nine separate but related chapters. Following the introduction in Chapter 1, a literature review in Chapter 2 provides background information on a number of research contexts, relevant for the thesis presented. The initial step was then to identify current practice in PA and healthy lifestyle promotion strategies and interventions in all 22 PICs. Therefore, Chapter 3 describes PA programmes in 20 out of 22 PICs. Eighty-four PA programmes were identified to be in existence in 2010; twenty-six of those were implemented in the workplace setting. Whilst monitoring and evaluation mechanisms are important to enhance programme effectiveness and to improve population health, findings from this study showed no evidence of monitoring and evaluation approaches in the region.
As a first step to respond to the absence of evaluation work, a formative evaluation of a healthy workplace programme in Port Vila, Vanuatu, was carried out. The aim was to understand the impact of an existing programme that commenced in 2007 (Appendix L). Findings indicate that Ni-Vanuatu women are at particular risk for physical inactivity16 and as such, are at higher risk for negative health consequences. This outcome was used to tailor a specific PA intervention for these women in greater detail.
Chapter 4 responds to the lack of empirical evidence on lifestyle behaviour and presents formative work carried out with Ni-Vanuatu female civil servants. The study identifies barriers and facilitators for the engagement in PA and for the adoption of healthier lifestyles in urban Ni-Vanuatu women. Findings indicate that team-based walking activities are the preferred mode of PA for the target group in Vanuatu. Further, fun-centred approaches may prove effective in increasing PA behaviour. Identified barriers include time, financial limitations, family commitments, environmental aspects and motivational hindrances. These findings were used to design a culturally-meaningful workplace PA programme that responds to local realities and needs.
The workplace-based PA intervention is described in detail in Chapter 5. In summary, a team-based pedometer challenge titled Wokabaot Jalens (Walking Challenge) was designed in collaboration with Ni-Vanuatu female civil servants. The 12-week intervention was implemented with 207 participants in Port Vila, Vanuatu, in April 2011. As an important part of the intervention, local leaders were trained to a) collect accurate data and b) take ownership of the programme after the monitored phase had terminated. Baseline (N=207) and follow-up (N=133) health screenings were conducted to understand the physical effect of the intervention. Pedometers provided an objective measure of PA behaviour.
Overall, pedometer-based research has predominantly focused on outcomes, with limited or no information regarding programme processes. A process evaluation was conducted in Chapter 6 to understand the effectiveness of the intervention and to provide recommendations for the adjustment and design of future programmes. A novel technique of visualising complex data is provided and a new approach in health promotion research is presented. The new thematic data visualisation (TDV) approach aids non-academics in understanding scientific data in a simple way. This may engage local health practitioners and potential donor agencies to support and initiate future action. Evaluation findings indicate that likert-scale questions have little value in PICs which is assumed to be due to a cultural inclination to assent with external ideas. Open-ended questions, however, revealed more information. Thematic findings indicate that positive health outcomes are the most desired programme effect; that unmotivated team members were considered as counterproductive; that an expansion of the programme to the wider community was the dominant suggestion for programme improvement; and that motivational issues were the biggest challenge for programme participation.
Previous research (Australia, USA) indicates that walking interventions can be effective, at least in the short term, to increase PA levels in women. However, no research has been undertaken to understand whether this strategy is effective in Pacific women. The efficacy of the Wokabaot Jalens was therefore assessed in Chapter 7. Qualitative and quantitative probabilities were calculated to assess the magnitude of inference. Conclusions are based on inferential statistics that emphasise precision of estimation rather than null hypothesis testing (P values). Overall, a positive effect was identified for PA behaviour which increased by 26.1% (2,513 ± 6,922). High risk individuals benefitted most from the intervention: a large positive effect was identified for PA behaviour (large, +229%). Positive effects were also found for waist circumference (moderate, -6.2%) serum glucose (small, -15.9%) and triglycerides (moderate, -31.%).
Chapter 8 provides an ethnographic investigation that describes the challenges and successes of managing health promotion programmes experienced by the researcher in different PICs (Vanuatu, Tuvalu, Tonga, Kiribati), taking cultural values into consideration. In particular, programme logistics, on-site issues, opportunities and challenges for health promotion programme sustainability, limitations and success stories are reported. The previously designed intervention from Vanuatu serves as an example to describe hands-on experience. Context specific issues that were observed during Pacific health promotion initiatives were categorised into thematic findings and classified as individual, cultural and external barriers and facilitators. Whilst individual issues (attitude, perception, acceptance, distribution) were largely identified as facilitators for health promotion action, cultural (structures, communication, language, gender, dress code, data precision) and environmental issues (climate, funding, conduct, geographical remoteness) may challenge health promotion efforts. The presentation of this reflective praxis is intended to aid future practitioners and researchers in programme design, management and evaluation and seeks to enhance collaboration with local personnel and authorities.
Finally, Chapter 9 describes the intricacies of external factors responsible for the Pacific health crisis. These include genetic susceptibilities, globalisation and contemporary environments, a heavy dependence on external aid, a limited Pacific health workforce, underfunded political systems, and last but not least individual lifestyle behaviours and choices. The chapter concludes that only culturally-centred health promotion approaches which take the attitude and belief system into account are realistic to result in Pacific health progress.
In summary, this doctoral work provides the first robust approach of evidence-based solutions for PA health promotion efforts in the Pacific region. This work is valuable in the context of the absence of evidence around programme efficacy, and other formative and process evaluation seen as best practice in health promotion. Yet it is hard to see an optimistic future in controlling the spread of NCDs in the region because of the complexities involved.
If a medical emergency is defined as a large amount of human suffering and preventable premature death, then yes, the PICs are in a state of medical emergency. The current state will likely remain until profound social and economic changes are set into process.