DEVELOPMENT OF A POLICY BRIEF TO FACILITATE THE IMPLEMENTATION OF THE PHYSICAL ACTIVITY/SPORTS POLICY IN RWANDA Lela Mukaruzima Student No: 2959943 A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy in the Department of Physiotherapy, Faculty of Community and Health Sciences, University of the Western Cape Supervisor: Professor José M. Frantz May 2018 ABSTRACT The importance of health enhancing physical activity participation (HEPA) has always been emphasized globally, as one of the means to reduce the risk of Non-Communicable Diseases (NCDs) occurrence. In Africa, it is more relevant currently, due to the growing burden of NCDs that is coupled with the existing encumbrance of communicable diseases. In Rwanda, specifically, there are limited national strategies to promote health-enhancing physical activity. Consequently, the level of physical activity among Rwandans, especially government office workers, is likely to diminish, which could possibly be attributed to the rapid urbanization that comes with lifestyle changes. Basically, most people tend to abandon the traditional labour-intensive activities, which are associated with high energy expenditure, to more sedentary activities. Therefore, the need to promote health enhancing physical activity participation is crucial. Physical activity participation is an intricate and multifaceted behaviour that may not be viewed from a linear perspective. This current study adopted a socio-ecological framework to assess the factors that influence Leisure Time Physical Activity (LTPA) among government employees in Kigali City. The study used an exploratory, sequential, mixed methods of qualitative and quantitative designs, in order to comprehensively explore and understand the research problem. Qualitatively, a Case study and exploratory design was used to collect data, specifically from the Rwanda Sport Policy and its implementing stakeholders. Quantitatively, a cross-sectional, descriptive design was used to assess and describe the levels of LTPA among government workers in Kigali City, as well as highlight the various factors that influence, or limit, their participation. Data were collected in four phases, commencing with a review of the Rwanda Sports Policy as phase one. The policy was reviewed using the ADEPT and Linear policy process models. In the second phase, semi structured interviews were conducted with thirteen key stakeholders of the Sports Policy, who were purposively selected. The aim was to explore their opinions and experiences, regarding the policy, and how it is implemented. The third phase was a survey among 521 government workers in Kigali City, who were conveniently selected from a stratified population sample. Their demographic profiles were assessed, as i http://etd.uwc.ac.za/ well as their levels of physical activity, and the factors that influence their participation. Data were collected using the Godin Shephard Leisure Time Physical Activity Questionnaire (GSLTPAQ), which was customized to add the demographic section, and the open-ended questions to assess the factors that influence participation. Finally, the fourth phase was an online survey with thirteen purposively identified experts in the field of physical activity, using a snowball approach. The survey sought their opinions, regarding best practices for the promotion of health enhancing physical activity. The qualitative data were analysed, using thematic analysis and the Atlas.ti, while the quantitative data were analysed, using Statistical Package for the Social Sciences (SPSS), version 23. The study findings revealed that the Rwanda Sports Policy does not overtly promote the Sports for Health programme; however, the health benefits of sports are automatically linked to participation. There was a disconnection between policy and practice. Besides the weak collaboration among stakeholders, as well as other challenges cited that generally affected the policy implementation, most of the stakeholders implied that there was an absence of a well- planned strategy to promote the Sports for Health programme. More than half (61%) of the participants were not sufficiently active. Chi-square tests revealed that Leisure Time Physical Activity (LTPA) was significantly associated with years of working (p=.002), as well as with age (p=.004). The prevention of diseases and to maintain good health were some of the major motivators for engaging in LTPA. Lack of time, fatigue and not being motivated, emerged as the major factors that hindered the participants to be physically active. However, the main aim of the Rwanda Sport Policy was to advance professional sports in Rwanda. Although the policy and its stakeholders acknowledged that the health benefits of sports are intrinsically part of participation, less efforts were invested in realizing it. Based on the overall study findings, shortcomings were identified regarding the role of the Rwanda Sports Policy, in promoting the Sports for Health programme. In addition, high levels of inactivity were revealed among government office workers. Therefore, recommendations were made, based on the socio-ecological model, as well as on the opinions of the physical activity experts. ii http://etd.uwc.ac.za/ There is a need for specific strategies that aim to promote health enhancing physical activity. The strategies should be contextualized to consider individual, the social and physical environmental factors that influence physical activity participation among individuals. Finally, policy interventions are required to reinforce stake-holder collaborations, regarding the initiatives to promote health enhancing physical activity. For example, policies on the regulation of prices at sports facilities could be introduced, as well as a tax rebate on sports, or gym equipment. In addition, the provision of sports facilities within communities or residential areas, and the creation of walking, or running tracks would serve as enablers for physical activity participation. iii http://etd.uwc.ac.za/ KEY WORDS Policy brief Sports policy Socio-ecological model Stakeholders Leisure time physical activity Health promotion Non Communicable Diseases iv http://etd.uwc.ac.za/ LIST OF ABBREVIATIONS ADEPT Analysis of Determinants of Policy Impact EDPRS Economic Development Poverty Reduction Strategy GGDP Good Governance and Decentralisation Policy GSLTPAQ Godin Shephard Leisure Time Physical Activity Questionnaire HEPA Health Enhancing Physical Activity HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome LSI Leisure Score Index LTPA Leisure Time Physical Activity MDGs Millennium Development Goals METs Metabolic Equivalents MINALOC Ministry of Local Government MINEDUC Ministry of Education MINISANTÉ Ministry of Health MNISPOC Ministry of Sports and Culture MOD Ministry of Defence NCDs Non Communicable Diseases NHRC National Health Research Committee ODI/SciDev Net Overseas Development Institute/Science and Development. Network PSF Private Sector Federation v http://etd.uwc.ac.za/ RNOC Rwanda National Olympic Committee RNP Rwanda National Police SDG Sustainable Development Goals SPSS Statistical Package for the Social Sciences WCPT World Confederation for Physical Therapy WHO World Health Organization vi http://etd.uwc.ac.za/ DECLARATION I declare that “Development of a policy brief to facilitate the implementation of the physical activity/sports policy in Rwanda” is my own work, that it has not been submitted for any degree or examination in any other university, and that all the sources I have used or quoted have been indicated and acknowledged by complete references. Name: Lela Mukaruzima Date: May 2018 Signature: …………………………………………… vii http://etd.uwc.ac.za/ DEDICATION I dedicate this piece of work to the Lord God Almighty, the great “I AM” of my life “I can do all things through Him, who gives me strength” Phil’ 4:13. To my lovely papa and mama, Mr. & Mrs. Rutwaza, and to my siblings, thanks for your unconditional love, your spiritual and emotional support, they kept me going even when it was tough. Last but not least, I dedicate this thesis to Dr. Ben Karenzi, my second father. Words cannot express my gratitude towards the unceasing love, generosity, kindness and encouragement that you showed me the whole time. May God’s unconditional blessings and favour be your portion forever! viii http://etd.uwc.ac.za/ ACKNOWLEDGEMENTS I give thanks to the Lord God, for his Grace and Mercy that has seen me through, thus far, and for fulfilling His promise to me. To Him be Glory and Honour. I profoundly thank my supervisor, Professor José Frantz, for her professional guidance, encouragement, patience and divine wisdom. Thank you for believing in me and reassuring me that I could make it. You have been an inspiration to me in many ways and it has been amazing working under your guidance (which I prefer to call anointing). May God richly bless you. To the Hon. Dr Eugene Mutimura, I genuinely appreciate and acknowledge your invaluable contribution to my work, while still my co-supervisor. Special thanks to all the participants of this study, who willingly and generously provided me with the information that I needed. To my research assistants, for assisting me with the data collection. To my writing/statistical coach through the UWC Division for Post-Graduate Studies (DPGS) for his assistance with data analysis and critical feedback. I am highly indebted, to the Rwandan government through the Rwanda Education Board, for granting me a study loan