|Year : 2020 | Volume
| Issue : 2 | Page : 141-147
Frequency, intensity, time, and type principle of physical activity as a medical disability prevention program in ethiopia: a mixed-method study
MD Kassa1, JM Grace2
1 Postdoc Researcher, College of Health Science, Department of Biokinetics, Exercise and Leisure Sciences, University of KwaZulu-Natal, Durban, South Africa
2 Associate Professor, College of Health Science, Department of Biokinetics, Exercise and Leisure Sciences, University of KwaZulu-Natal, Durban, South Africa
|Date of Submission||23-Nov-2018|
|Date of Decision||03-May-2019|
|Date of Acceptance||29-Apr-2020|
|Date of Web Publication||16-Jun-2020|
M D Kassa
College of Health Science, Department of Biokinetics, Exercise and Leisure Sciences, University of KwaZulu-Natal, Durban
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Despite the recognized benefits of physical activity (PA), the extent of its recognition and applications as a medical disability (MD) prevention program by practitioners working in Ethiopian health-care settings is unknown. Objective: The objective of the study was to explore health-care professionals' knowledge base and characteristics on the utilization of the frequency, intensity, time (duration), and type principle (FITT) of PA as an MD prevention program in the Ethiopian public health-care system.Methods: A mixed-method research design was used with data collected from 13 public referral hospitals in Ethiopia. In Phase I, quantitative data were collected from 312 health professionals (99 physicians and 213 nurses) using a survey. In Phase II, qualitative data were collected by interviewing health officers (n = 13 physician–hospital managers) and conducting one focus group discussion (n = 6 national health bureau officers). Results: A quarter (28%) of practitioners working in referral hospitals are using PA as an MD prevention program. Higher specialization (adjusted odds ratio [AOR] = 20.203, P < 0.001), many service years (AOR = 0.041, P = 0.014), young age (AOR = 19.871, P < 0.001), and being male (AOR = 0.269, P < 0.001) were associated with using PA as a MDs prevention program. Conclusion: Applying the FITT principle of PA for the prevention of MD among practitioners was very poor. Training of health-care professionals to use PA as a program for MDs prevention is required at the undergraduate level as well as specialized courses on qualification.
Keywords: Employment duration, exercise counseling, health promotion, health workforce, specialist
|How to cite this article:|
Kassa M D, Grace J M. Frequency, intensity, time, and type principle of physical activity as a medical disability prevention program in ethiopia: a mixed-method study. Indian J Public Health 2020;64:141-7
|How to cite this URL:|
Kassa M D, Grace J M. Frequency, intensity, time, and type principle of physical activity as a medical disability prevention program in ethiopia: a mixed-method study. Indian J Public Health [serial online] 2020 [cited 2021 May 7];64:141-7. Available from: https://www.ijph.in/text.asp?2020/64/2/141/286816
| Introduction|| |
Engaging in regular physical activity (PA) decreases the risk of medical disabilities (MDs), such as cardiovascular disease, diabetes, hypertension, and obesity which constitutes 38 million deaths or 70% global mortality annually., MDs affect many nations, including low-income countries, and account for 40% of its annual deaths in Ethiopia., The majority of MDs share common risk factors, such as tobacco use, alcohol intake, unhealthy meal, and insufficient PA. Various MDs can be prevented by addressing the behavioral risk factors, specifically through PA, which, despite its numerous health benefits, remains inadequately used at a global level.
Scientists recognize PA as the “perfect” medicine, considering a comprehensive range of benefits, it can provide for health. Butler stated that “If PA could be packed in a pill, it would be the single most widely prescribed and beneficial medicine in the nation.” However, despite its acknowledged health benefits, the lack of PA has reached epidemic levels, and it is one of the top four MDs risk factors in the world, causing morbidity and mortality in global populations., To minimize the growing epidemic of physical inactivity, the American College of Sport Medicine developed primary PA recommendations for healthy adults which suggests participation in moderate intensity aerobic PA for a minimum of 30 minutes for 5 days a week, and perform PA that maintain and increase muscular strength and endurance for a minimum of 2 days a week. However, evidence shows that nearly 60% of the population worldwide is less likely to meet the suggested level of regular PA of moderate-intensity or vigorous-intensity PA/week. Moreover, the lack of PA has shown to be associated with 6% of coronary heart disease, 7% of type 2 diabetes, 10% of colon cancer, 10% of breast cancer, 9% of premature mortality, and 6 million global deaths annually., In this regard, researchers indicate that an increase in PA of 10%–25% will prevent 1.3 million premature annual deaths that are associated with MDs.,
Globally, a range of initiatives have been established and implemented to overcome the low levels of PA, such as the exercise is medicine global health initiative, which considers “PA” to be a medicine that physicians need to prescribe, and the Bangkok Declaration on PA for global health and sustainable development., Studies show that doctors who communicated and counseled their patients about healthy lifestyles and PA positively influenced their patients to involve in a regular program of PA., Nevertheless, little is known about the health-care professionals' characteristics in promoting and applying PA as a program for MDs prevention in the Ethiopian health-care system. Therefore, this study aimed to investigate the knowledge base and characteristics of health professionals' on the utilization of PA using the frequency, intensity, time, and type principle (FITT) as a MDs prevention program in Ethiopian public hospitals.
| Materials and Methods|| |
Study design and setting
A mixed-method sequential explanatory research design was conducted from September 2017 to October 2018 among physicians and nurses working in 13 referral hospitals. This manuscript forms part of a bigger study, and the participants of the study are similar to a different set of objectives and results from the bigger study.
Study subjects and sampling
From nine regional states and two administrative cities of Ethiopia, 13 referral hospitals from four regions and Addis Ababa Administrative City were randomly selected. The 13 referral hospitals (three from Amhara, two from Benishangul-Gumuz, four from Oromia, two from Southern Nations and Nationalities People Region (SNNP), and two from Addis Ababa city) were purposively sampled because the selected referral hospitals are currently the only hospitals providing tertiary service on MDs in no small number of the community in their respective region than other hospitals. Of the 475 nurses, 213 were selected using a sample size calculator (Survey system, 2018). The remaining 99 participants were physicians who were selected using purposive sampling because the physicians were the available specialists working on MDs treatment and prevention with exceptional knowledge in the sampled regions and selected hospitals. Finally, the nurses (n = 213) were assigned to the 13 referral hospitals using a proportionate stratification sample size determination equation.
The study was conducted in two phases due to the explanatory sequential design, the first being quantitative and the second qualitative. In Phase I, 99 physicians were purposively selected and 213 nurses proportionately and randomly. For the second (qualitative) phase, 13 hospital managers, who are all qualified medical doctors, and six national health bureau officers were purposively selected to participate. Participants were considered for inclusion in the study if they had had 3 years or more work experience treating MDs in a hospital setting.
Self-administered questionnaires were developed and validated by conducting a pilot study on 30 practitioners from two other hospitals not included in this study. Questionnaire items were scored on a dichotomous scale capturing “Yes” and “No” responses.
In Phase I, health-care professionals who met the inclusion criteria completed questionnaires, which consisted of two sections: the first section obtained the participants' demographic characteristics and the second addressed the practitioners' knowledge base and utilization of the FITT principle of PA as a program for MDs prevention.
In Phase II, interviews and one focus group discussion (FGD) were conducted to investigate participants' personal opinions, knowledge, and the utilization of the FITT principle of PA to prevent MDs in the Ethiopian health-care system. Interview/FGD guide included one question/item for an interview and two items/questions for FGD. The interviews (n = 13 physician–hospital managers) and one focus group (n = 6 national health bureau officers of the Ethiopian Ministry of Health) were taped and conducted by two researchers.
Ethical clearance was obtained from the University's Biomedical Research Ethics Committee (reference number HSS/0683/015D last approved on December 10, 2017), and administrative permission to conduct the study in Ethiopia was obtained from the Ethiopian Ministry of Health. Informed consent was obtained from each participant according to the 1964 Helsinki declaration and its later amendments.
In Phase I, the Statistical Package for the Social Sciences v. 24 (IBM SPSS Statistics for Windows, version 24 (IBM Corp., Armonk, N.Y., USA)) was used to analyze the quantitative data. Descriptive statistical analysis was performed to determine the sociodemographic characteristics (Section 1), as well as the responses per category to the 12 questions in Section 2 of the questionnaire. The responses to each of the 12 questions were summed and presented as a percentage, with a binomial test being used to determine whether a significant number (P value) of respondents replied “Yes.” Of the 12 items, those participants who responded “Yes” to 7 or more for all 12 questions were coded as 1 and considered to use PA as a strategy to prevent MDs. Binary logistic regression analysis was then conducted to predict practitioners' use of the FITT principle of PA as a program to prevent MDs, and the scores were statistically analyzed to establish the odds ratio (OR). The Omnibus Chi-square test was used to ensure the goodness of statistical model significance. All tests were conducted to show a 95% confidence interval (CI) and to recognize a 5% level of significance.
In Phase II, qualitative data from the interviews and focus group were transcribed and transferred into the NVivo 11 software program (NVivo 11 (QSR International Pty Ltd)) with data being analyzed with a thematic content analysis method.
| Results|| |
Phase I: Quantitative component
The participants' sociodemographic characteristics [Table 1] indicate a higher number of women respondents (n = 195, 62.5%), with the majority being less than the age of 33 years (59.6%). Married respondents accounted for 81.7% and more than half (67.0%) were general nurses. Specialist physicians accounted for 5.4%, with 23.1% being general physicians. The majority of the respondents had an employment duration of 3–8 service years (57.4%), with only a few (4.2%) having 15–20 years of service.
[Table 2] presents the response to the 12 questions in descending order of those responding “yes.” It shows (questions 1–5) that over 30 of the participants reported discussing PA, their benefits, and difficulties they may encounter with their patients. However, few health practitioners engaged with their patients about the frequency, duration, intensity, and type of PA they should engage in questions 6–9. Even fewer questions (10–12) develop and provide their patients with written information to increase their PA levels. When each respondent's scores for the 12 questions were averaged by their “Yes/No” reply, those who had an average score of ≥7 for using PA as a strategy for MDs prevention accounted for 28% of all the health-care professionals.
|Table 2: Binomial test on frequency, intensity, time, and type principles of physical activity as a medical disabilities' prevention program|
Click here to view
The logistic regression analysis shows gender, age, employment duration, and specialization as strong significant predictors to use the FITT principle of PA as a MDs prevention program in Ethiopian hospitals [Table 3]. Female health-care professionals are less likely to use the FITT principle of PA as a program than male health-care workers (OR: 269, 95% CI: 0.130–0.556, P < 0.001). Those under the age of 33 years considered PA as a program for MDs prevention more likely than those over 34 years (OR: 19.871, 95% CI: 4.531–87.146, P < 0.001). Health-care workers with 3 to 8 years of service (OR: 0.041, 95% CI: 0.003–0.521, P = 0.014) and those who had 9 to 14 years' employment duration (OR: 0.085, 95% CI: 0.009–0.796, P = 0.031) were less likely to use PA as a MDs prevention program compared to those with employment duration d15 years'. Furthermore, general physicians are more likely to use the FITT principle of PA as a MDs prevention program than nurses (OR: 20.203, 95% CI: 7.594–53.744, P < 0.001).
|Table 3: Odds rato of gender, age, service year, and specialization health.care professionals with the use of frequency, intensity, time, and type principles of physical activity as a strategy for medical disabilitiesf prevention|
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The Omnibus Tests of Model Coefficients used to test the goodness of the model was statistically significant, indicating that the predictors as a set reliably distinguished the users and the nonusers of the PA program (Chi-square = 147.100 with df = 19, P < 0.001).
Phase II: Qualitative component
Results from the interviews with the 13 physician–hospital managers (1 question) and the FGD with the six ministries of health national health bureau officers (2 questions) are presented below.
Interview on the utilization of PA and its link to medical disabilities prevention
Question 1. How do you evaluate the utilization of the FITT principle of PA as a program to prevent MDs in your hospital healthcare system?
The respondents' indicated that the FITT principle of PA is less likely to be used in the health-care system as a program of MDs prevention practice in their hospitals.
“…the use of the FITT principle of PA is not part of the healthcare system in our country as a result of an uneducated public attitude about it. If PA was part of the community life, it could be easy to use it as a MDs prevention mechanism in the healthcare system” Interview Participant (IP) (IP: 1, 7, and 12). The interviewers also argued “…making PA part of the lifestyle of the community can help its integration into the healthcare system for disease prevention. If not, it will be challenging to incorporate it into the healthcare system as clinical practice” (IP: 2–5).
In no hospitals, PA has been incorporated and used as clinical practice for disease prevention in the health-care system. “…the existing situation is discouraging because engaging in PA programmes by any means is viewed as redundant among both healthcare providers and the community” (IP: 6, 9, and 13). Experience and lifestyle of the health-care workers also determine the use of PA as a program of MDs prevention. “…in my view, few practitioners may recommend PA to their patients as MDs prevention strategy if they are experienced it”(IP: 8 and 10).
Participants maintained that the prevention of MDs using PA program requires the coordination of different elements in the health-care system.“…the use of a PA program for clinical practice needs a responsive patient, committed healthcare providers and an environment that encourages active lifestyles. However, such components are poorly integrated into our hospitals” (IP: 1, 3, 6–13).
The health-care professionals' belief in PA averts them not to use PA as a program of preventing MDs. “…traditionally, partaking in PA is believed as wasting time, and this wrong belief may influence healthcare professionals' use of PA as part of medical care in our healthcare system” (IP: 3 and 4).
The poor public awareness about the health benefit of PA blocked the motivation of health-care workers' use of PA in clinical practice “…taking part in a PA program as recreation or for health purposes being an adult is considered a shame—children grow-up with such a perception regarding PA. In such community, it is challenging to integrate PA into the healthcare system for clinical practice” (IP: 1, 5 and 6).
All respondents agreed that the health-care experts' knowledge on the FITT principle of PA for clinical practice is positive. However, they lack knowledge on how to prescribe PA to people with MDs.
“…to be honest, the majority of healthcare professionals' have adequate understanding of the role of PA in preventing MDs. However, most practitioners lack the practical skill and knowledge on the specific type of PA, the frequency, duration, and intensity of the PA that must be prescribed. The premises behind this could be the lack of PA related courses included in medical students' curriculum in Ethiopia” (IP: 1–13).
Focus group discussions on restraints to use PA as a program to prevent medical disabilities
Question1. What are the restraints to use the FITT principle of PA as a MDs prevention program?
According to the focus group discussants, using PA for clinical practice in the health-care system can help with the prevention of premature death-related MDs. However, different restraints may avert the use of PA and the FITT principle as a MDs prevention program.
Despite the acknowledged health benefits of PA, priority given to it in the clinical practice for MDs prevention is associated with the individualities of health-care professionals (FGD: P1, P3, and P4). Being male, young age, being a physician, high academic status such as having different training, and length of work experience with medically disabled patients among the practitioners could be some of the characteristics affecting the use of PA for MDs prevention (FGD: P2, P5, and P6).
The discussants identified the absence of PA as a disease prevention program in the national health-care policy as well as the lack of manuals that guide practitioners to prescribe PA as a problem.
The situation in our healthcare system is a little bit different, particularly regarding MDs. It lacks the FITT principle of PA as a program to prevent MDs and associated manuals that help practitioners to apply it in the healthcare system as a clinical practice (FGD: P1, P5, P6).
Inadequate understanding of the health benefits of PA among patients with MDs and health-care professionals' lifestyles are associated with the use of PA as clinical practice. “…as to me, PA is poorly viewed as a medicine by the majority of the society including literate citizens. Similarly, inadequate PA behaviour of healthcare professionals may affect their use of PA, FITT principle for MDs prevention” (FGD: P2). The discussants point outpatients' unwillingness to accept PA as a part of clinical practice to prevent their MDs. “…it is difficult to recommend PA to medically disabled people because they never accept it. The majority of them prefer drug prescription or an injection than a planned PA program” (FGD: P3, P4 and P6).
Question 2. How good is the knowledge of the practitioners' to apply the FITT principle of PA as an MDs prevention program in the current healthcare system?
The discussants explicitly stated, “…healthcare professionals' who have personally experienced at least one of the MDs in their life and used PA as a preventive program, may apply it in the healthcare system as a medical practice for their patients” (FGD: P3 and P4). In addition, a discussant stated “… practitioners who enrolled for shortand long term training on how to prescribe PA to specific MDs may use it for clinical purpose” (FGD: P6). Similarly, a discussant stated”…most probably healthcare professionals' with knowledge on PA, FITT principle and having an active lifestyle background, may apply it for the prevention of MDs” (FGD: P1).
The participants also indicated PA as nationally irrelevant with almost zero attention. “.I do not think PA has national relevance, possibly the lack of government attention like other MDs prevention mechanisms. I can witness that using PA as a MDs prevention program is unusual in the current health-care system. The government is more concerned over prescribing drugs to treat MDs after its occurrence” (FGD: P4).
In conclusion, health-care professionals' lack of confidence and knowledge regarding the FITT principle of PA to be applied contributes to the exclusion of PA as a program to prevent MDs. “…the practitioners' poor knowledge and fear (patients' resistance to accepting PA as an intervention program) can be causes that avert practitioners' application of the FITT principle of PA for MDs' prevention” (FGD: P3 and 5). The discussants stated,“short term in-service training can help practitioners on how to screen medically disabled people for PA, and on the utilisation of the PA FITT principle” (FGD: P3 as agreed by P1, P2, P4–6).
| Discussion|| |
This study is the first of its kind to report on health-care professionals' knowledge base and characteristics on the use of the FITT principle of PA as a MDs prevention program in the Ethiopian public health-care system, indicating that a staggering 78% of health professionals do not use the FITT principle of PA as a program to prevent MDs. Even though these results are consistent with the previous studies,, they differ from a study in Ireland which showed the practice of PA by practitioners to prevent MDs. The possible reason for the difference could be attributed to lack of knowledge, confidence, skill, and interest among health professionals in Ethiopia to counsel their patients about PA to prevent MDs. Other probable reasons could be the absence of long- and short-term training for health professionals on how to use PA in health-care settings in Ethiopia. Studies reflect that where PA training was included in the curriculum of medical students, they showed improved skills, knowledge, and confidence in counseling patients about PA. Moreover, the sedentary lifestyle of Ethiopian health professionals may prevent them from using PA as a program to prevent MDs in the health-care system. However, in contrast to our finding, a study in two health-care centers of Saudi Arabia showed that primary health-care practitioners who were physically active imparted PA counseling to their patients, with similar evidence in Ghana, Kenya, and South Africa.
The results of our study exemplified gender, age, years of service, and specialization of health-care professionals as the strongest predictors of using PA as a strategy to prevent MDs. The above was found to be autonomously associated with utilization of PA as a strategy to prevent MDs in hospitals. The finding that female health professionals are less likely to use PA than males are consistent with a study in rural Kerala, India. The gender difference of using PA as a program to prevent MDs could be attributed to their lifestyles, with women being less physically active than men.
The results of our study indicate that health professionals under the year of 33 years utilize PA as a program for MDs prevention compared to those over 34 years. Other researchers who indicated that health professionals of a higher age are less active and therefore reluctant to prescribe PA support this finding. The results also revealed that specialists and general physicians use PA as a program to treat MDs compared to nurses. The finding of higher utilization of PA by specialists and general physicians than nurses is supported by a study in Brazil. Similarly, the results of our study are consistent with research in Brazil that reported that physicians are more likely to use PA and counsel their patients compared to nurses. Health professionals with more years of service were most likely to use PA as a MDs preventive strategy compared to fewer service years. This could be associated with their constant engagement with other health professionals over time and exposure to varying opinions, which enables them to improve their knowledge and understanding of how to address various conditions.
Inconsistent with our findings, researchers in Brazil indicated that physicians, nurses, and community health-care workers counseled their patients on PA. The difference could be attributed to the variation in the health-care policy of the two countries, with PA being regarded as part of health care in Brazil, unlike the Ethiopian health-care system. Similar to our results, researchers in Ireland indicated that general health professionals' use of written advice about PA is low that is associated with a shortage of time, high workload, and lack of skill and knowledge about PA, such as the type, frequency, intensity, and duration.
| Conclusion|| |
This research has highlighted the inadequate use of the FITT principle of PA as a MD prevention program by health professionals in the Ethiopian public health-care system. Inadequate knowledge and training of Ethiopian health professionals on the utilization of the FITT principle also needs to be addressed. It is thus of utmost importance to train health professionals at the undergraduate and postgraduate level and offer specialized courses on qualification on the utilization of the FITT principle of PA as a MDs prevention program.
The authors acknowledge the editors and the families who participated in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Miller KR, McClave SA, Jampolis MB, Hurt RT, Krueger KL, SarahCB, et al
. The health benefits of exercise and physical activity. Curr Nutr Rep 2016;5:204-12.
WHO. Noncommunicable Diseases Progress Monitor. Vol. 46. Geneva: WHO; 2017.
WHO. Noncommunicable Diseases Country Profiles. WHO; 2018.
Endriyas M, Mekonnen E, Dana T, Daka K, Misganaw T, Ayele S, et al
. Burden of NCDs in SNNP region, Ethiopia: A retrospective study. BMC Health Serv Res 2018;18:520.
Butler RN. If exercise could be packed in a pill, it would be the single most widely prescribed and beneficial medicine in the nation. Exerc Med 2012;43:1-37.
Dacey ML, Kennedy MA, Polak R, Phillips EM. Physical activity counseling in medical school education: A systematic review. Med Educ Online 2014;19:24325.
Piggin J, Bairner A. The global physical inactivity pandemic: An analysis of knowledge production. Sport Educ Soc 2016;21:131-47.
ACSM. American College of Sport Medicine (ACSM) Primary Physical Activity (PA) Recommendations. ACSM; 2018.
Riebe D, Franklin BA, Thompson PD, Garber CE, Whitfield GP, Magal MP, et al
. Updating ACSM's recommendations for exercise preparticipation health screening. Med Sci Sports Exerc 2015;47:2473-9.
Wen CP, Wai JP, Tsai MK, Chen CH. Minimal amount of exercise to prolong life: To walk, to run, or just mix it up? J Am Coll Cardiol 2014;64:482-4.
Lobelo F, Stoutenberg M, Hutber A. The exercise is medicine global health initiative: A 2014 update. Br J Sports Med 2014;48:1583.
Hidalgo KD, Mielke GI, Parra DC, Lobelo FS, Eduardo JG, Grace OF, et al
. Health promoting practices and personal lifestyle behaviors of Brazilian health professionals. BMC Public Health 2016;16:1-10.
Lin ML, Huang JJ, Chuang HY, Tsai HM, Wang HH. Physical activities and influencing factors among public health nurses: A cross-sectional study. BMJ Open 2018;8:e019959.
Nvivo. NVivo Qualitative Data Analysis Software (2017) QSR International Pty Ltd. Version 11; 2017.
Bezner JR. Promoting health and wellness: Implications for physical therapist practice. Phys Ther 2015;95:1433-44.
O'Brien MW, Shields CA, Oh PI, Fowles JR. Health care provider confidence and exercise prescription practices of Exercise is Medicine Canada workshop attendees. Appl Physiol Nutr Metab 2017;42:384-90.
Joyce CL, O'Tuathaigh CM. Increased training of general practitioners in Ireland may increase the frequency of exercise counselling in patients with chronic illness: A cross-sectional study. Eur J Gen Pract 2014;20:314-9.
Brennan AM, Urzo KA, Fenuta AM, Houlden RL. Integrating exercise counseling into the medical school curriculum: A workshop-based approach using behavior change techniques. Am J Lifestyle Med 2017;20:1-24.
Teferi G, Kumar H, Singh P. Physical activity prescription for non-communicable diseases: Practices of healthcare professionals in hospital setting, Ethiopia. IOSR J Sport Phys Educ 2017;4:54-60.
Banday AH, Want FA, Alris FF, Alrayes MF, Alenzi MJ. A cross-sectional study on the prevalence of physical activity among primary health care physicians in aljouf region of Saudi Arabia. Mater Sociomed 2015;27:263-6.
Holtzhausen L. Exercise is medicine South Africa. Div Sport Exerc Med Sch Med 2013;27:1-38.
Aslesh OP, Mayamol P, Suma RK, Usha K, Sheeba G, Jayasree AK. Level of physical activity in population aged 16 to 65 years in rural Kerala, India. Asia Pac J Public Health 2016;28:53S-61S.
Kyung M. Relationships among physical activity level, health-promoting behavior, and physiological variables in Korean University students. Perspect Nurs Sci 2018;15:11-7.
Lobelo F, de Quevedo IG. The evidence in support of physicians and health care providers as physical activity role models. Am J Lifestyle Med 2016;10:36-52.
Ramos LR, Malta DC, Gomes GA, Bracco MM, Alex AM, Gregore IP, et al
. Prevalence of health promotion programs in primary health care units in Brazil. Rev Saude Publica 2014;48:837-44.
[Table 1], [Table 2], [Table 3]