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Measures and indicators of physical activity in surveillance, monitoring, and evaluation of Primary Health Care in Brazil: a scoping review

Medidas e indicadores da atividade física na vigilância, monitoramento e avaliação da Atenção Primária à Saúde do Brasil: uma revisão de escopo

Medidas e indicadores de la actividad física en la vigilancia, monitoreo y evaluación de la Atención Primaria de Salud de Brasil: una revisión de alcance

Review of physical activity in PHC in Brazil

Valter Cordeiro Barbosa Filho¹
https://orcid.org/0000-0002-4769-4068
Jaqueline Aragoni da Silva²
https://orcid.org/0000-0001-6344-9073
Marcus Vinicius Veber Lopes³
https://orcid.org/0000-0002-7968-5211
Kelly Samara Silva²
https://orcid.org/0000-0002-7356-1680

1 – Center for Research and Innovation in Collective Health, Health Sciences Centre, Ceara State University, Fortaleza, Ceara, Brazil.
2- Center for Research in Physical Activity and Health, Sports Centre, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil.
3 – Healthy Active Living and Obesity Research Group, Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada.

Address:
Valter Cordeiro Barbosa Filho
Núcleo de Pesquisa e Inovação em Saúde Coletiva. Av. Dr. Silas Munguba, 1700 - Parangaba, Fortaleza, Ceará, Brasil.
ZIP CODE: 60714-242.



 
ABSTRACT
The study aimed to map physical activity (PA)-related measures and indicators that are considered in Primary Health Care (PHC/SUS) surveillance, monitoring and assessment. This scoping review was conducted in January 2024 in electronic portals, searching for government materials that aimed at these strategies of PHC/SUS with PA indicators. The selection and extraction processes were performed in pairs, and a thematic synthesis was used. Of the 239 potentially eligible documents, 95 were included on surveillance (n=39), plans/policies (n=7), user (n=34) and service (n =15) monitoring/assessment. A total of 69 measures and 38 different indicators were addressed in health surveillance. Service monitoring/assessment includes general and specific PA programs (17 and 13 indicators, respectively). User monitoring/assessment included indicators aimed at people from different groups (e.g., people with chronic diseases) and their application, primarily in initial examinations and therapeutic planning. This study reinforces a call for government actions aiming to qualify the acquisition and implementation of PA-related health information; this may be one the main pathways of strengthening PA promotion on the SUS agenda.
DESCRIPTORS: Motor Activity; Epidemiologic Surveillance Services; Health Assessment; Evidence-Informed Policy; Brazilian Healthcare system.



 
Introduction
Physical activity (PA) has been a relevant component of the public health policy agenda in Brazil. Among the various historical milestones of the Brazilian Healthcare system (In Portuguese, Sistema Único de Saúde - SUS), we can highlight the inclusion of PA and physical practices as one of the priority axes in the 2006 Brazilian National Health Promotion Policy (In Portuguese, Política Nacional de Promoção da Saúde - PNPS)1 and in 2021, with the launch of the Physical Activity Guide for the Brazilian Population2. This is consolidated with the expansion of the offer of public programs of physical exercise, sports, body practices and other actions that can represent PA in Primary Health Care (PHC)3,4.
Although the PA agenda in PHC/SUS has been strengthened3,4, recent reports on PHC/SUS management have highlighted the need to improve information monitoring to support PHC/SUS management, including those related to PA promotion actions5,6. This is reinforced in the plans to tackle non-communicable chronic diseases and injuries for the 2011-20227 and 2021-20308 cycles, in the Brazilian National Primary Care Policy9 and in the Brazilian National Health Surveillance Policy10, which highlight the need to strengthen the integration of information on healthcare services and health indicators in the population.
Therefore, it is necessary to carry out research and actions that aim to improve and integrate the “surveillance, information, assessment, and monitoring” axis as part of PHC/SUS7,8. Actions that integrate the elements of this axis allow us to understand how SUS can respond to the population’s social and health demands, monitor and assess access to essential healthcare services, and monitor users assisted by services that combat morbidity in the population. This allows for the systematic and integrated monitoring of government information that favors decision-making for healthcare, human resources management and health program management11,12. Therefore, it strengthens SUS and the Brazilian population’s health7,8.
Reviews summarized measures, indicators and instruments related to PA from different countries and age groups13–17. However, these studies do not detail how this information is integrated into SUS service and user surveillance, monitoring, and assessment, which makes it difficult to transfer these results for inclusion in the specific healthcare services of the Brazilian system. In 2022, a scoping review17 mapped national surveys involving measures related to PA (and sedentary behavior) in 12 South American countries, including Brazil. However, this review did not consider other elements of the “surveillance, information, assessment, and monitoring” axis7,8, such as changes in measures and indicators related to PA between historical series of these surveys and aspects that constituted SUS service and user monitoring and assessment. Another study4 highlighted the advances in the monitoring of PA programs in Brazil from 2006 to 2014, but did not consider other actions implemented after 20145,6. Therefore, a study that summarized the different government information on the interrelated axes of surveillance, monitoring and assessment can elucidate the different nuances, needs and advances of an important part of the PA agenda aimed at PHC/SUS.
Considering the multidimensionality of PA (the behavior itself and the psychosocial and contextual factors associated with it)18 is also a necessary element in the PA agenda in PHC/SUS. For instance, there are historical changes in recommendations related to PA (variation in types of physical exercises and volume of PA)18 as well as alignments and specificities between physical practices and PA in official SUS documents2,19. Also, there are dubious interpretations in the use of the terms “PA” and “sedentary behavior” and their definitions, which are often and mistakenly considered as single behaviors (e.g., “active lifestyle” or “being sedentary”)20. A study that summarizes these different components, respecting their specificities, can contribute to the dimensions of measures/indicators related to PA that are considered or need to be improved in PHC/SUS, which can subsidize the technical-scientific support that underpins public policy decisions in the field of public health.
In this regard, this study aimed to map information (measurements and indicators) related to PA that are considered in government documents for PHC/SUS service and user surveillance, monitoring and assessment in Brazil.

Method

This study is a scoping review because it uses an evidence synthesis method that allows mapping key concepts, types of measurement and gaps related to a broad and relevant research question21,22. Methodological decisions followed JBI manual guidelines 21. The protocol and Supplementary Materials have been registered and archived for open access under the number 7jygq in the Open Science Framework (https://osf.io/7jygq/?view_only= 7c6f8a8aeca94fa192486a92de04864a). The study was reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews guidelines (Supplementary Material 1)22.

Question and selection criteria
The guiding question of this review was based on elements of the PCC approach (Population, Concept and Context)21: “What measures and indicators related to PA (concept) are included in government documents on PHC/SUS service and user surveillance, monitoring and assessment?” 21.
Considering the focus of this study on government documents and strategies, it was decided to consider eligible all types of documents that represented institutional materials (technical reports, technical manuals, guidance booklets, electronic web pages of the Federal Government portal, among others). The inclusion of these documents is recommended in scoping reviews that target issues related to government policies and programs, as it allows the coverage of data sources that contemplate these elements21.
Documents were eligible when they presented the following characteristics:
1) Aimed at PHC/SUS1, i.e., focused on promotion, protection or prevention programs and services in the social or collective sphere, linked to the low complexity level of care9;
2) Focused on one of the axes of PHC/SUS operationalization8,23: i) health surveillance, such as national surveys to identify diseases and their risk factors and conditions; ii) national plan and PHC/SUS healthcare service monitoring/assessment; and iii) PHC/SUS user monitoring/assessment;
3) Mention measures (items, response scales or open questions) or indicators (metrics derived from the measures consolidated in an assessment matrix, such as the percentage of compliance with PA recommendations) related to PA. To represent the multidimensionality that PA has in the PHC/SUS agenda2,23, documents with any of the measures/indicators related to PA were considered. This included individuals’ behavior and factors directly related to PA, such as psychosocial factors (e.g., motivation) and contextual factors (e.g., provision of PA programs), due to their relevance as indicators of PA in the population18. Since PA and sedentary behavior have been considered concomitantly in different health policies/programs in Brazil2, information on sedentary behavior – when addressed as a component of PA – was also presented separately. When the measures/indicators referred to PA with the term “body practices”19, this information was also considered and described specifically.
Documents were excluded from this review when they did not present the characteristics previously described or when they presented duplicate information; in these cases, the most detailed document was kept in the review. No limits on year of publication or language of publication were applied.

Information sources and search and selection strategy
Considering the complex nature of this review and government repositories, manual searching with the “snowballing” strategy was adopted21,24. Therefore, electronic databases indexing scientific journals were not included in the search, due to the eligibility of government documents, which tend to be reached with complementary strategies25,26. To this end, electronic portals from the Ministry of Health (portal “gov.br”), the Department of Primary Health Care and other government sectors (e.g., Virtual Health Library and Brazilian Institute of Geography and Statistics) that describe intersectoral actions involving PHC/SUS were consulted. Supplementary Material 2 details the complete list of electronic portals.
The search process for eligible documents was carried out in July 2022 and updated in January 2024. Initially, the descriptors “physical activity” and “body practices” were used in the search fields of the electronic portals. Then, as part of the “snowball” strategy, the content of each page was assessed, and potentially relevant documents were captured. Indications of new electronic pages were also checked until saturation (repetition) of potentially eligible materials was reached. Finally, the references of documents were consulted as part of the document search strategy (Supplementary Material 2)22,27.
In the initial selection process (search and screening), each document was reviewed by two of the three reviewers (CGS, LV or NDM), and disagreements were resolved by a third reviewer (VBF, JAS or KSS, see supplementary material 2). A new round of selection based on the complete documents (eligibility) was then performed by two reviewers (JAS and VBF) and, when there were disagreements, consensus meetings were held. The agreement rate among reviewers in the eligibility process was 92.5% (supplementary material 3). The document search and selection process was illustrated according to the PRISMA flowchart (Figure 1)28.

Information extraction and synthesis
The information from included documents was extracted by one of the researchers and reviewed by another (VBF, JAS and MVL). Disagreements in extraction were discussed until a consensus was reached. To this end, an Excel spreadsheet was previously prepared and coded by researchers experienced in scoping reviews (VBF, KSS, MVL and JAS), containing information on document identification (title, objective and year of publication), PHC/SUS axis (service and user surveillance, monitoring/assessment), characteristics of the population group of interest and information on measures/indicators related to PA.
The documents were summarized in the three operational axes of PHC/SUS: (1) health surveillance; (2) national plan and healthcare service monitoring/assessment; and (3) user monitoring/assessment8,23. Documents on the same program, policy or plan were labeled with their corresponding name to facilitate understanding of the thematic convergences arising from the same government actions. Supplementary Material 4 details the documents included according to the label adopted in the study synthesis.
Thematic synthesis was carried out in this review due to the multidimensionality, complexity and scope of the content extracted from documents, as recommended in the JBI manual21. The process of organizing and categorizing the content was carried out during extraction by one of the authors and validated in consensus meetings among the authors (VBF, JAS and MVL), until the themes were no longer repeated, i.e., theoretical saturation28. Thematic evidence maps were produced to illustrate the results28.
In surveillance documents, measures/indicators related to PA were themed by survey and age group (children, adolescents, adults, and older adults) in three dimensions: 1) PA domains2 (free time, commuting, household chores and work/school); 2) psychosocial and contextual factors of PA; 3) measures/indicators of sedentary behavior (Figure 2 and Supplementary Materials 4 to 6). The documents with information on healthcare service and user monitoring/assessment were described according to the types and names of PHC/SUS programs and their thematized measures/indicators. Thematic graphs of evidence were produced according to the population groups of interest, when possible (Figures 3 and 4).

Results

Document selection and description process
Of the 239 potentially eligible documents (Supplementary Material 2), 79 were excluded in initial screening because they did not present information related to PA. Of the remaining 160 documents, 65 were excluded because they did not meet the inclusion criteria (see Supplementary Material 3). Thus, 95 documents were included in the final review (Figure 1), which are listed in Supplementary Material 4. Of these, 39 dealt with health surveillance, 15 with service monitoring/assessment, seven with monitoring of PA in national plans and 34 with user monitoring/assessment.

PA in health surveillance
The 39 health surveillance documents are described in Figure 2 and Supplementary Materials 4 and 5. These documents describe five different national health surveys, covering children (Brazilian National Study of Child Food and Nutrition (In Portuguese, Estudo Nacional de Alimentação e Nutrição Infantil - ENANI), adolescents (Brazilian National School Health Survey (In Portuguese, Pesquisa Nacional de Saúde do Escolar – PeNSE), adults and older adults (Brazilian National Household Sample Survey (In Portuguese, Pesquisa Nacional por Amostra de Domicílios - PNAD), Brazilian National Health Survey (In Portuguese, Pesquisa Nacional de Saúde - PNS), and Surveillance of Risk and Protective Factors for Chronic Diseases by Telephone Survey (In Portuguese, Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico - VIGITEL) (see Supplementary Material 4 for details of the documents).
PA measures varied considerably between the surveys analyzed. ENANI included measures that included PA in leisure time and overall PA in Brazilian children from a federal program aimed at this population. PeNSE included measures of overall PA and in the commuting and school, psychosocial and contextual factors of PA, and sedentary behavior domains. There were fluctuations, such as the inclusion or exclusion of PA measures between the years of PeNSE (Figure 2).
Surveys of Brazilian adults and older adults also included several measures of PA. PNAD (2015) presented a set of measures focused on general PA and sports practice, separately. For both, measures focused on leisure time, and global measures and psychosocial factors were identified. PNS (2013 and 2019) presented measures of the four PA domains, such as psychosocial and contextual factors of PA, and sedentary behavior. VIGITEL (2006-2023) focused on measures of the four domains of PA and sedentary behavior. In general, few changes were observed in PNS and VIGITEL measures between the surveys over time (Figure 2).
When summarizing the PA indicators presented in health surveys (Supplementary Material 5), it was observed that the measures previously presented are described in isolation or from the combination of variables to construct indicators similar to those established in scientific literature, such as compliance with PA recommendations. However, there are variations in indicators over time, due to the differentiation in data treatment, which makes comparability impossible.

PA in PHC/SUS service monitoring and assessment
Fifteen documents presented measures/indicators on monitoring and assessment of healthcare services involving PA in PHC/SUS, detailed in Supplementary Material 4. Two thematic categories emerged in the synthesis: PHC/SUS assessment programs; and programs offering services in PHC/SUS (Figure 3).
Nine documents addressed information on two assessment programs: the Self-Assessment for Improving Access and Quality of Primary Care (In Portuguese, Autoavaliação para Melhoria do Acesso e da Qualidade de Atenção Básica - AMAQ) and the Brazilian National Program for Improving Access and Quality of Primary Care (In Portuguese, Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica - PMAQ). These documents detailed 17 measures/indicators related to PA actions in Basic Health Units, the School Health Program, and services focused on users with chronic diseases. One PMAQ indicator focused on users’ perception of access to PA programs (Figure 3).
Six documents described 13 measures/indicators for monitoring and assessing PA in specific PHC/SUS programs (Figure 3 and Supplementary Material 4). Measures/indicators on motor performance during PA practice (such as active play) were considered in child assessment in the Happy Child Program. In the Health Academy Program (In Portuguese, Programa Academia da Saúde – PAS), several measures/indicators on PA actions were recommended, with an emphasis on the structure, process, results and management of this program. Measures/indicators related to autonomy, participation, planning, replication and sustainability were recommended for assessing successful PA practices in PHC/SUS. Measures/indicators to assess the scope and implementation of the guide in management and in healthcare services related to PA were included in the document of recommendations for managers and healthcare professionals for implementing the Physical Activity Guide for the Brazilian Population. Finally, measures/indicators on PA actions offered in healthcare services were also included in the Federal Financial Incentive for Physical Activity Funding (Figure 3).
Different measures/indicators were observed in national health plans, focused primarily on monitoring the prevalence of leisure time PA in adults and in healthcare services that encompass PA (e.g., implementation of PAS hubs) (Supplementary Material 6).

PA in PHC/SUS user monitoring and assessment
Thirty-four documents described PA measures/indicators for monitoring and clinical assessment of users from different population groups, which were detailed in Supplementary Material 4. The contents of these documents were themed around central health assessment questions (Whose? In what context? What? How?) (Figure 4).
In general, PA measures/indicators are recommended for different age groups (children, adolescents and older adults) and for populations with different health conditions: pregnant women, people with chronic diseases, obesity, hypertension, type 2 diabetes mellitus, acute myocardial infarction, heart failure, stroke, obstructive pulmonary disease, asthma, breast cancer, dementia, alcohol use disorder, and depression. It is worth highlighting the recommendation to use electronic forms and medical records (in particular, the Collective Activity Form, included in e-SUS) to assess and record users involved in PA and collective activities offered in PHC/SUS (Figure 4).
For children up to six years of age, motor performance assessment during PA (e.g., active play) is recommended during home visits and routine consultations. In the care lines aimed at children and adolescents, recommendations were observed for assessing regular PA practice, psychosocial factors of PA (e.g., interest in PA) and sedentary behavior. In older adults, there is an emphasis on activities of daily living, functionality and psychosocial factors of PA (interest in PA in free time and in PA programs) (Figure 4).
In general, PA assessment is included in clinical examinations and consultations in PHC/SUS so that therapeutic planning (lines of care) can be implemented. It was observed that, for people with chronic diseases and obesity, PA assessment encompasses more detailed measures/indicators, including behavior, psychosocial factors of PA and participation in PA offered in PHC/SUS. For the other groups, PA assessment is not detailed and is done through open-ended questions to patients, being directed at cardiovascular risk factors (physical inactivity) and the identification of symptoms and signs of disease severity (e.g., among people with asthma) (Figure 4).

Discussion

To the best our knowledge, this study is the first to map a wide range of information on measures/indicators related to PA in government documents on surveillance, PHC/SUS user and service monitoring and assessment. This is important, as it allows an understanding of the efforts to integrate information related to PA in PHC/SUS as well as the needs for advances in actions in this axis of the Brazilian system.
A positive result of this study was the finding of measures/indicators for different age groups (children, adolescents, adults, and older adults) in the Brazilian National Health Surveillance System. This is consistent with the Brazilian and international agenda for promoting PA in the life cycle2. At the same time, it is clear that there is variability in information on PA between surveys (69 measures and 38 different indicators). For instance, while PeNSE (2009-2019) includes measures/indicators in all dimensions, ENANI 2019, given its proposal to assess motor development, included some information on PA (Figure 2). It is understandable that surveys with complex objectives and broad territorial coverage balance validity and feasibility in data collection, which makes it difficult to measure some behaviors with higher quality, such as PA18,29. At the same time, our findings reinforce the urgent need for national surveys that consider the multidimensionality of PA in their measures/indicators, especially in children2,30.
This review highlighted changes in measures/indicators between series of the same national surveys (Figure 2 and Supplementary Material 4). An example of this occurred in PeNSE between 2009 and 2019, where there were changes in the items and calculations of the percentage of adolescents who met PA recommendations31. This makes it impossible to use this information in behavioral trend analyses and, consequently, understand how public health policies benefit this population. Despite this, Brazil has shown good examples in the continuity of health measures/indicators and in the use of tools (e.g., dashboards)32,33 to facilitate communication and interpretation of continuity of these health indicators for health managers and communicators34.
A relevant aspect of this study was the summarization of different information on PHC/SUS service monitoring and assessment, whether from assessment programs or from the provision of services involving PA. Minatto et al.25 found national PA policies in 64 countries, but only eight (not including Brazil) reported monitoring and assessment as part of these policies. Another review summarized 34 documents on the assessment of the implementation of health promotion actions (including PA and other priority axes of PNPS) in Brazilian municipalities and found a great diversity of designs, methods and instruments for monitoring/assessing PA, even within the same programs29.
However, a relevant result of this study was the summary of measures/indicators already existing in PA promotion programs in PHC/SUS (for instance, PAS, Incentive to PA and Recommendations for Successful Practices in PA in PHC/SUS)5,6. These documents include tools and information that support the planning, implementation and assessment of the scope and direct results on the health of users of PA programs. Given the challenges and divergences in the process of assessing health programs in Brazil29, there is also a need for strategies to define and implement tools that already exist in PHC/SUS routine work and services.
It was observed that PA is included in the Health Information Systems for Primary Care (In Portuguese, Sistemas de Informação em Saúde para a Atenção Básica - SISAB), mainly with the Collective Activity Form with records of PA actions. This plays a fundamental role in the effective promotion of PA in PHC/SUS governance11, as it allows monitoring and assessment of users involved in these services35,36, impacting the financing and monitoring of PA programs37. Nevertheless, it was evident that user PA assessment in the Health Care Network seeks to guarantee comprehensive care9 not only focused on age groups, but also on users with specific health conditions, such as pregnant women, among others.
In this scenario, the wide diversity of information, measures and indicators in each line of care is striking. While some lines of care (older adults and children and adolescents) detail instruments that have demonstrated validity and reliability to assess PA or associated constructs (motor development or functionality)38,39, most were based on subjective questions (e.g., “asking about risk factors, such as physical inactivity”) as part of clinical assessment (Figure 4). Measures without guaranteed validity and reliability limit the care network’s capacity to achieve some of its objectives, such as: 1) reliable and valid user monitoring and assessment in PA as an important health factor, 2) the use of information as part of therapeutic planning involving PA; and 3) estimating changes and the effectiveness of healthcare services in the population’s PA5,9,34.
Considering the findings of this study, some implications can be suggested to add to the research and practice agenda on PA in PHC/SUS. To this end, researchers, specialists, managers and policy and health program makers can consider these findings to:
(a) enable the inclusion, in national surveys, of PA measures and indicators as a relevant health indicator, especially in groups with few measures/indicators, such as children;
(b) strengthen the quality and continuity of an assessment matrix of measures/indicators related to PA that can be consolidated to support the improvement and quality of PHC/SUS in promoting PA and health;
(c) promote continuing education courses and other health education technologies that can expand managers’ and professionals’ knowledge and skills in the use of monitoring and assessment instruments for PA services in PHC/SUS, including for filling out systems and forms that are part of SISAB;
(d) seek to integrate existing PA monitoring and assessment tools (e.g., Recommendations for Successful Practices in PA in PHC/SUS and SISAB records on PA) into healthcare care lines, aiming to expand resources that support healthcare professionals in PHC/SUS (including nurses, physiotherapists, social workers, among others) to include PA in care comprehensiveness.
This study also has limitations. The first involves the complexity of searching for documents when they are not systematized in databases. During the study, the Federal Government’s domain was transferred to the “gov.br” portal, which resulted in relevant information being hosted on more than one electronic portal. Although the comprehensive search had repeated steps by more than one researcher to avoid selection bias, it is possible that some eligible documents were not found in this process. Another limitation was the scope of documents included and the information extracted, even within each theme (surveillance, monitoring and assessment). Therefore, the implications presented here focus on expanding new research and studies on the theme, but do not allow defining services and practices to be implemented in the services – a limitation inherent to scoping reviews21.
In conclusion, measures/indicators related to PA are covered in a comprehensive, diversified and even inconsistent manner (with variations between cycles) in PHC/SUS, considering the government documents that deal with user and healthcare service surveillance, monitoring and assessment. Gaps and weaknesses were also highlighted, such as few PA measures/indicators for surveys in some population groups (e.g., surveys aimed at children) and the low integration between monitoring and assessment of users and existing PA programs. These results reinforce a call to prioritize actions to qualify the acquisition and implementation of health information related to PA in political decisions, planning and management of PHC/SUS.

Authors’ contributions:
Study design and planning: VCBF, KSS. Data collection, analysis, and interpretation: VCBF, JAS, MVVL. Preparation of the first draft of the manuscript: VCBF. Review, substantial contributions to the content, and approval of the final version: VCBF, JAS, MVVL, KSS.

Acknowledgements
We would like to thank researchers CGS, LV and NDM for their contributions to the process of searching and selecting documents in the screening phase.

Research funding:
Individual grants to K.S.S (n: 305803/2020-4) and V.C.B.F (n: 312091/2021-4) from the Brazilian National Council for Scientific and Technological Development (In Portuguese, Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq) Productivity Grant. Individual grants to J.A.S. from the Coordination for the Improvement of Higher Education Personnel (In Portuguese, Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES). The above-mentioned agencies had no influence on the review content or conduct.

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