Physical Activity in Africa

Home , Risk factor

April 11-12 London 2013! The Global Healthy Workplace !"#$%#&'()*+),-.$/)0#1$(/2#$) The Workplace:Awards a Key & Summit Setting will to highlight:Fight ! Chronic Disease in Emerging Countries

! The importance of employer health programmes! A South African! The emerging Perspective better practices and innovations ! ! Opportunity to replicate around the world! Non-Communicable Disease in Sub- Saharan Africa NON-COMMUNICABLE DISEASES IN AFRICA 3

70 with the term ‘Africa south of the Sahara’. We used 60 the limit function to limit search results to articles in 50 English and to human studies. In order to identify 40 studies reporting prevalence, incidence and mortality of each condition, we repeated the search excluding 30

Per cent Per review articles (MeSH NOT ‘Review’). Data were ex- 20 tracted using a standard form (S.D. extracted data on 10 heart diseases, stroke and cancer, J.J.B. extracted data 0 on diabetes mellitus type 2). We also consulted art- 2000 2005 2010 2015 2020 2025 2030 icles listed in references of retrieved articles and from discussions with colleagues with SSA experience. Year Our inclusion criteria were community-based studies Non Communicable disease Noncommunicable diseases Communicable disease conducted in any SSA country that reported on disease or risk factor prevalence, incidence or mortality InjuriesCommunicable diseases Maternal, perinatal, nutritional Injuries for each of the key diseases in our investigation (heart Dalal S, Beunza JJ, Volmink J et al., 2011. Int J Epidemiol.diseases, stroke, diabetes mellitus type 2 and cancer). Maternal, perinatal, nutritional We excluded hospital-based studies as they are not Figure 1 Estimated proportions of age-standardized representative of the general population because of mortality rates by cause in SSA. SSA mortality estimates widespread lack of health-care access. Hospital-based were standardized to the WHO World Standard Population. studies were used to extract data on diabetes mellitus Source: WHO. Global Burden of Disease. Projections of complications. Due to the comparatively small

7 Downloaded from mortality and burden of disease, 2002–2030. number of studies we did not use criteria for evaluat- ing the quality of the study. We did not restrict our search to specific dates, and made every attempt to

obtain older articles (for example, those published in ije.oxfordjournals.org Similarly, the INTERHEART study that included nine the 1960s and 1970s). We read at a minimum each African nations and 43 other countries found that five abstract to screen for relevance, and read in full those risk factors (smoking, hypertension, abdominal obes- which met our inclusion criteria. We also analysed publicly available WHO Global ity, diabetes mellitus and elevated ApoB/ApoA-1 ratio) at University of Cape Town on May 26, 2011 accounted for 90% of the risk for a first myocardial Burden of Disease and WHO STEPS data sets on esti- infarction in the African sites.14,19 mated and projected causes of death for different Other social and environmental changes in SSA also world regions and prevalence of diabetes mellitus in likely play a role such as changes in air quality and SSA. We analysed the International Agency for early childhood exposures.15,20 These lead to increased Research on Cancer (IARC) public databases for prevalence of NCD risk factors such as hypertension, cancer incidence and projections for SSA. abdominal obesity and abnormal blood lipids.1,15,20 If action is not taken, one estimate shows that US$84 billion in lost productivity could occur due to heart disease, stroke and diabetes in the 23 low- and Results middle-income countries (four of which are in SSA), Search results for cardiac diseases excluding review which would account for 80% of worldwide NCD papers returned 1494 manuscripts, 1201 of which mortality by 2015.8 were in English and limited to human studies Thus, NCDs represent a largely ‘silent’ epidemic in dating from 1965. The stroke search yielded 149 SSA. We review the literature and summarize World manuscripts; 127 met the criteria for language and Health Organization (WHO), and International human studies. Diabetes mellitus search results were Agency for Research on Cancer (IARC) data on 348 overall, with 321 in English and humans. The NCDs in SSA with the goal of reporting on the reported prevalence of heart diseases, stroke and burden of NCDs measured by morbidity and mortality diabetes mellitus from community-based studies are and the prevalence of NCD risk factors. provided in Tables 2–4; all numbers are for crude Due to the large scope, we were not able to address prevalence unless otherwise noted. Crude and neuropsychiatric diseases and chronic lung diseases. age-standardized cancer incidence from five cancer registries included in the IARC database are presented in Table 7. Commonly reported risk factors in the literature Methods from community-based studies of CVDs in SSA are We searched the Medline database using National reported in Table 5; hypertension, smoking and obes- Library of Medicine Medical Subject Heading ity were the most frequently reported. Half (50%) of (MeSH) search terms to cover each condition. These these studies were conducted in South Africa. Alcohol were ‘heart diseases’, ‘stroke’, ‘diabetes mellitus type use, hypercholesterolaemia and sedentary behaviour 2’ and ‘Neoplasms not Benign Neoplasms’ combined were infrequently measured. Non-Communicable Disease in Sub- Saharan Africa Disproportionate burden of both infectious and chronic diseases compared to other world regions.

Cardiac diseases and their risk factors are increasing in SSA.

25 (Source: NFCS; Steyn et al. 2005)

Complex relationship between20 overweight and underweight

15 Diabetes prevalence ranges from 2.5% in Seychelles to 16% in DR- 1-8 yrs) Congo (WHO-Steps) 10 5 Prevalence (% of ages children Prevalence Lack of health resources0 leads to late diagnosis, poor blood glucose Obese Wasting Stunting control. Overweight Underweight

Additionally burdened by rheumatic heart disease, HIV/AIDS and other factors that impact on cardiovascular outcomes. Dalal S, Beunza JJ, Volmink J et al., 2011. Int J Epidemiol. Compeng health agenda: global view of HIV infecon 2007

UNAIDS 2008

• 67% of all people living with HIV (22 million) are in SSA

• 60% of whom are women

• Limited access to ARV’s and those who are have increased risk of dyslipidemia and dysglycemia Physical Activity in Africa

120

100

60 Men

Women 40

Guthold R, Louazani SA et al 2011, Am J Prev Med Burden of Disease in South Africa

Cause of Death (per 100 000 population)

1000 Communicable HIV/AIDS 750 NCD Injuries 500

250 Population (per 000) 100 0 Men Women Persons Group

Bradshaw et al., SA BOD: Estimates of Provincial Mortality 2000 Risk Factor Proﬁle of SA Employees

South African Employees (n=11 472)

100 At risk 80 No Risk e g

a 60 t n e c

r 40 e P 20

0 Chol BMI BP PA Smoking Behaviour

Patel et al., 2012, JOEM Physical Activity and Additional Risk factors for NCD

Physical 0 1 2 3 4 Acvity Addional Addional Addional Addional Addional Risk Factor Risk Factor Risk Factor Risk Factor Risk Factor

Physically 88 223 211 114 30 Acve

Inacve 168 591 815 481 157

Chi-square: 43.55; p <0.00001

Kolbe-Alexander, 2013, in preparaon Risk Factors and Healthcare Ulisaon

Healthcare expenditure and risk factor profile

The number and cost of doctors visits is signiﬁcantly higher in the group with more than 2 risk factors, even aer adjusng for age and use of chronic medicaon Working on Wellness: WOW

Aim

The main aim of this study was to measure the eﬀecveness of a worksite health promoon programme on improving health behaviour and associated biological risk factors for CVD among South African employees at increased risk for cardiovascular diseases. Methodology: Participants

Parcipants Eligibility Criteria SCORE: 10% of more BMI > 30 Not pregnant, at least 12 months remaining if contract worker

Process

Randomisaon Eligible Wellness SCORE at company employees Day Calculated level invited

Intervenon Control

Kolbe-Alexander et al., , BMC Public Health, 2012 Wellness Day Measures

Measurements: Health Risk AssessmentClinical Measures

Height Cholesterol Glucose Blood Pressure Weight (Finger prick) (Finger prick) BMI Self Report Measures

Healthcare Expenditure

Doctor ‘s visits Hospitalisaon Chronic Out of pocket & cost Medicaon expenses

Kolbe-Alexander et al., , BMC Public Health, 2012 Total 6-I 3-I CTL Participant Characteristics(n=762) (n = 194) at(n = Baseline153) (n = 415) Male/ female % 47% / 43% 37% / 55% 48% / 39% 44% / 46%

Age (years) 37.8 (9.9) 37.7 (9.6) 41.0 (10.9) * 36.7 (9.5) #

BMI (weight/ height2) 32.8 (5.7) 33.8 (5.0) 33.5 (5.5) 32.2 (6.1) §

Waist (cm) 101.3 (13.1.0) 101.1 (10.6) 102.9 (12.7) 100.9 (14.4)

Systolic Blood 126.5 (14.6) 125.0 (14.1) 128.6 (14.4) 126.5 (14.9) Pressure (mmHg)

Diastolic Blood 82.6 (11.4) 82.4 (11.0) 83.6 (10.5) 82.3 (11.9) Pressure (mmHg) Total Cholesterol 4.7 (1.1) 4.7 (1.1) 5.0 (1.1) * 4.6 (1.0) # Physical Activity 120 (60) 120 (90) 120 (60) 120 (60) (minutes/week) [median and mode}

Total Number of risk 2.6 (1.1) 2.6 (1.0) 2.8 (1.1) 2.4 (1.1) factors

• 6-I and 3I significantly different; # 3-I and CTL significantly different; • § 6-I and CTL significantly different Working on Wellness Preliminary Results

BMI Waist SBP DBP Chol Glucose Sing Days Time Ill health

INT 6

INT 3

CTL

Kolbe-Alexander et al., , BMC Public Health, 2012 The Discovery Healthy Company Index: Using organisaonal aributes to promote workplace physical acvity in South Africa Discovery Health’s obejcves of HCI

1) publicise the workplace as a setting for health improvement;

2) document employer health promotion efforts in this area and recognize organizations adopting best practices; and

3) assess the health behaviors of employees at companies that aspire to become the healthiest companies in South Africa.

Patel et al, 2012, JOEM Research opportunies from HCI

Article: JOM201673 Date: October 3, 2012 Time: 17:34 ORIGINAL ARTICLE

The Healthiest Company Index A Campaign to Promote Worksite Wellness in South Africa

Deepak Patel, MD, MSc, Ron Z. Goetzel, PhD, Meghan Beckowski, MPH, Karen Milner, MA, PhD, Mike Greyling, MSc, Roseanne da Silva, BScHons, FIA, Tracy Kolbe-Alexander, BSc, PhD, Maryam J. Tabrizi, MS, and Craig Nossel, MBChB, MBA

achieve population health improvements and cost savings.12 Further- Objective: To describe a 2010 initiative to encourage companies in South 1) To esmate the burden of chronic diseases of lifestyle more, recent evidence suggests that worksite health promotion pro- Africa to adopt workplace health promotion programs. Data doc- Methods: grams can achieve a positive return-on-investment of approximately umenting organizational efforts to improve workers’ health were collected $3.00 saved to $1.00 invested for both medical- and absenteeism- from 71 participating employers and 11,472 workers completing health as- related costs.10 Other benefits include improved worker morale and sessments. Organizational and employee health were scored on the basis positive company branding. of responses to the surveys that asked about facilities and programs of- Although there is substantial research being performed on fered, leadership support for health promotion, and employees’ health status. this topic in the United States,12–14 very little information is cur- In its first year, the initiative recruited 101 organizations and 71 on South African companiesResults: rently available on the prevalence of health promotion initiatives at qualified for the award. Results aggregated across these companies focus workplaces in other countries and on the state of health and well- on elements constituting organizational and individual health, with specific being of international workers. measures that companies can review to determine whether they and their em- Against this background, Discovery Health, a South African ployees are “healthy.” The Healthiest Company Index provided Conclusions: private health insurer, initiated a joint project with researchers from useful baseline data to support employers’ efforts to develop and implement the Departments of Psychology and Statistics and Actuarial Science effective and impactful health promotion programs. at the University of the Witwatersrand in Johannesburg, the Human Biology Department at the University of Cape Town, and the Institute for Health and Productivity Studies at Emory University to identify 2) To assess the prevalence of worksite facilies cross the globe, and more recently in South Africa, the work- and study the “healthiest” companies in South Africa, on the basis within A place is being recognized as an important setting for initiating of a set of metrics that evaluated individual employee and overall health promotion programs aimed at improving the health and well- company “wellness.” This article describes the initial launch of the being of employees.1–6 There are compelling reasons for this new Healthiest Company Index initiative, which garnered participation interest, primarily related to the increasing burden of chronic dis- from 71 employers and 11,472 of their workers. eases on individuals, organizations, communities, and societies. According to the World Health Organization, in 2005 noncom- South African workplacesmunicable chronic diseases (NCCD) accounted for approximately HEALTH PROMOTION IN SOUTH AFRICA 35 million deaths worldwide, with 80% of these deaths occurring In South Africa, the workplace has been a neglected arena in middle- and low-income countries.7,8 Current projections are that for health promotion, particularly in the area of NCCD. Like other chronic diseases will be responsible for 388 million deaths glob- transitioning economies, South Africa is experiencing a burgeoning ally in the next 10 years, and that 36 million of these deaths could epidemic of NCCD linked to lifestyle. Relative to baseline values potentially be prevented.9 in 1997, NCCD showed a fivefold increase in 2004.15 After human What makes these statistics more worrisome is that we now immunodeficiency virus and AIDS, lifestyle-related chronic diseases have the tools at our disposal to address modifiable health risk fac- are the leading causes of death and disability in South Africa.16 The tors, including smoking, physical inactivity, poor diet, high stress, epidemic growth of NCCD has been driven by major economic and and excess alcohol consumption, but we are not fully leveraging social changes that include rapid urbanization and dramatic changes 17 3) To assess the extent to which SA 8 employees engage in these tools. One underused tool is providing evidence-based health in individual lifestyle. These changes have been recorded in all promotion and disease prevention programs at the workplace. De- sections of the population but are most evident among employed spite mounting evidence recently assembled in careful literature individuals, with health insurance, living in urban areas.18 reviews10,11 that workplace programs improve the health of workers There is limited evidence18–20 that some companies in South and lower organizational costs, only a minority of employers offer Africa provide health promotion programs to their employees. comprehensive and multicomponent programs—the kind likely to According to Sieberhagen et al,21 employee wellness programs were healthful behaviours/acviesfirst introduced to the mining industry in the 1980s. In the last two From the Discovery Health (Dr Patel), Johannesburg, South Africa; Institute for decades, health promotion initiatives have been adopted by other Health and Productivity Studies (Dr Goetzel), Rollins School of Public Health, industries as well. Programs common among employers include [AQ1] Emory University, Atlanta, Ga; Truven Health Analytics (Dr Goetzel and training in occupational safety, employee assistance program, and Mss Beckowski and Tabrizi), Washington, DC; University of Witswaterstrand (Dr Milner, Mr Greyling, and Ms da Silva), Johannesburg, South Africa; screening and counseling for human immunodeficiency virus and University of Cape Town (Dr Kolbe-Alexander), Cape Town, South Africa, AIDS. Because of sparse financial and health improvement outcomes [AQ2] and Discovery Health (Mr Nossel), Johannesburg, South Africa. data, public knowledge and support for workplace health promotion Disclosure: The authors declare no conflict of interest. in South Africa are limited. Address correspondence to: Ron Z. Goetzel, PhD, Institute for Health and Productivity Studies, Rollins School of Public Health, Emory University, In conducting the Healthiest Company Index campaign, we [AQ3] and Consulting and Applied Research, Truven Health Analytics, 4301 sought to (1) publicize the workplace as a fruitful setting for health Connecticut Avenue, NW, Suite 330, Washington, DC 20008; E-mail: improvement, (2) document employer health promotion efforts in [email protected]. this area and recognize organizations adopting best practices, and (3) Copyright C 2012 by American College of Occupational and Environmental Medicine! assess the health behaviors of employees at companies that aspire to DOI: 10.1097/JOM.0b013e3182728d61 become the healthiest companies in South Africa.

• Employers enrolled • Provided list of eligible employees • Completed employer quesonnaire • Email invitaons to employees • Data collecon period • Incenves to respond

Patel et al, 2012, JOEM Employee and Employer Data Collected

• Vitality age as a basis – Combinaon of risk factors • BMI, Physical Acvity, Nutrion, Smoking, Alcohol, Chronic condions • Other measures – Health knowledge (4 tests) – Occupaonal stress – Movaon to change – Workplace facilies Response Rates 2011

Number of Number of Number of Response Rate employers employees responses

Small 28 1 813 1 028 56.7%

Medium 49 10 553 4 046 38.3%

Large 24 46 371 8 504 18.3%

101 58 737 13 578 23.1% Vitality Age: 2011 and 2012 Comparison Physical Acvity: 2011 versus 2012 Self-Reported Health Status and Risk Factor Proﬁle Most frequently reported worksite health promoon programmes

Wellness Iniave Prevalence One centralized locaon where employees can find informaon 49% about their health and wellness benefits and find relevant resources Cardiopulmonary resuscitaon training 49% Emergency preparedness training 45% Training to avoid workplace injuries and workplace safety promoon 35% Health Risk Assessment Incenves 25% Support and resources for managing chronic pain and 25% musculoskeletal injuries Pregnancy and childbirth preparaon classes and support 25% Ergonomic assessments and training 19% Automated external defibrillator training 11% Worksite Health Promoon for Physical AcvityElement Companies who offer Employees using this element element in last 12 months Stairwells that are well-lit, accessible, 86% 93% clearly marked Company sponsored fitness events 54% 38%

Showers and change room facilies 47% 39%

Physical acvity programs 40% 33%

Signs posted by elevators and stairwells to 19% Not asked encourage use of stairs Outdoor exercise areas such as ﬁelds, 18% 32% running tracks, walking trails Strength training equipment 16% 45%

Cardiovascular training equipment 15% 46%

Discounted memberships to oﬀ site 12% Not asked physical acvity facilies Physical Acvity and Self-reported health status

Physical Activity * 125 ) k y e t i

e 100 v i t w

c r A e

75 l p

a s c i e t

s 50 u y n h i P

m 25 (

Fair Poor Good Excellent Very Poor Self Reported Health Status

Kolbe-Alexander, 2012, in preparation Physical Acvity: Facilies and self reported behaviour

62 The number of facilities at each e r 61 company explained 5.4% of the o c S 60 variance in PA among employees y t i l i c 59 (r=0.054; p=0.036) a F

l 58 a t

o 57 T 56

8.0 e r

Total o

Inactive c

Phys Act S

y t

i 7.5 l i c a F

s 7.0 i c

The odds of employees r e x

meeting physical activity E 6.5 guidelines decreased by 17% (OR=0.83, 95% CI: 0,74-0,93) Total per one less facility at each Inactive Kolbe-Alexander, 2012,Phys Actin preparation worksite. Conclusion

• The burden of non-communicable diseases are increasing in Sub- Saharan Africa.

• South African employees are at increased risk of non-communicable disease (NCD).

• The worksite intervention program has some degree of success for improving clinical measures among employees at increased risk of NCD.

• The Discovery Healthy Company Index provides a benchmark of workplace health and intervention programs.

• The provision of physical activity facilities plays a small, but significant role on self-reported physical activity.

• Additional workplace interventions which aim to reduce the prevalence of risk factors for NCD is warranted.