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About City Move

CITY MOVE adapts and implements the WHO Global Action Plan on Physical Activity (GAPPA) in six cities across three continents and develops a cross-contextual evaluation framework for transferability and scalability.

 

Physical activity is a key behaviour to reduce the Non Communicable Disease burden, including protecting against cancers and type 2 diabetes. There are many evidence-based interventions for cities to promote physical activity, yet they remain under-implemented, with a whole-of-system approach particularly lacking, and often fail to target the least active or vulnerable groups.

 

Knowledge gaps are: a) how to adapt, b) successfully implement, and c) evaluate interventions, and d) how to transfer lessons to other interventions, target groups and contexts. In partnership with the cities, we identified interventions targeting individuals across the life course, particularly vulnerable and least active groups, aligned with the GAPPA domains of active people, societies, environments and systems.

 

CITY-MOVE will:

 

  1. Develop a city-GAPPA Theory of Change and operationalise assessment measures;
  2. Adapt city-GAPPA to six cities, engaging stakeholders in each context;
  3. Support cities in successful implementation through action research in living labs;
  4. Assess reach, adoption, feasibility, fidelity, and sustainability of selected interventions in each city;
  5. Improve the development and utilisation of routinely collected data to support successful implementation;
  6. Generate cross-contextual evidence on implementation, evaluation and scalability through multi-criteria decision assessment for 12 interventions in six cities; and
  7. Generate global capacity through regional Communities of Practice.

CITY-MOVE results lead to increased physical activity by target populations, contributing to reduced premature NCD mortality, and to adaptable solutions ready for take-up by implementers.

Objectives and ambition

Determinants of physical activity

Determinants of Physical activity at the level of the individual, social, built, and natural environment

Non-communicable diseases (NCDs) are the leading cause of death globally, 77% of which occur in low- and middle-income countries. Physical activity is one of the four key health behaviours that can reduce NCDs. Cities have the potential to address many determinants of physical activity through interventions in the built or social environment, enhancing PA in all population groups. While there are many evidence-based interventions to increase physical activity, many cities globally fail to (successfully) implement them.

 

CITY-MOVE (CITY Based interventions to stimulate active MOVEment for health)’s vision, therefore, is to support cities around the world to implement, monitor, and evaluate evidence-based interventions and policies to increase physical activity, and meet the WHO’s 2018 target of a 15% reduction in Physical InActivity by 2030.

 

Currently progress is still slow, unequal, and has been further impacted by the COVID-19 pandemic. CITY MOVE aims to accelerate progress by supporting six cities on three continents to implement an integrated package of evidence-based, adapted, and context-specific interventions. These interventions are aligned with the WHO Global Action Plan for Physical Activity (GAPPA) which addresses individual, social and built environment determinants of physical activity.

 

Beyond the six cities, transferable lessons will be shared and adapted through three regional and multi-stakeholder Communities of Practice. Physical activity is a key behaviour to reducing NCD burden. Globally, about 7.2% of all-cause and 7.6% of cardiovascular disease deaths, the leading cause of mortality, are attributed to physical inactivity. Over 69% of these deaths occur in middle-income countries. Physical activity reduces premature mortality, is protective against a range of NCDs including type 2 diabetes, several cancers, osteo-arthritis and dementia, it improves mental health and promotes healthy ageing. Between 2001 and 2016, physical activity averted 3.9 million deaths across the globe with the greatest gains in low income countries.

 

For example, beyond 15 minutes, every additional 15 minutes increase in daily exercise can reduce all-cause mortality by 4%. Physical activity is also key in dealing with obesity, another major NCD risk factor. Physical activity  interventions have also been associated with reduction in smoking, alcohol consumption, stress, and healthier eating habits. Despite the benefits of physical activity, globally, 81% of adolescents and a quarter (27.5%) of adults are physically inactive, estimated to cost healthcare systems about INT$ 47·6 billion per year. Although physical inactivity and its proportional contribution to NCDs is higher in high-income countries, its absolute burden is highest in low and middle income countries.

 

Physical activity is influenced by determinants in the individual, social, built, and natural environments, many related to city environment. The multi-level determinants interact and lead to a combination of barriers and opportunities unique in each city context and for different target populations. There is thus a need for contextualised and segmented approaches to address and monitor the variation and disparities in determinants and effects in a city context. However, many stakeholders lack knowledge and support in understanding which strategies are most effective and how to implement them.

About Physical Activity

There are large inequalities in physical activity and physical inactivity

Physical inactivity is more prevalent among women (43%) than men (38%). Individuals of lower income report lower leisure-time physical activity while those of higher income report lower occupational physical activity. Certain groups are particularly vulnerable to being excluded from physical activity, including adolescents, older people, people with disabilities, families in precarious life-situations, and migrants and ethnic minorities. Reasons include gender-stereotyping, lack of support programmes, underrepresentation, domestic responsibilities, perceived and actual danger, cultural attitudes and social roles. People in groups of low socio-economic status are doubly affected by the unequal distribution of options and risk. They often live in deprived areas with higher environmental risks such as reduced air and water quality, soil pollution, fewer green spaces, more urban heat islands, and limited safe infrastructure for walking, cycling, and active living. They also have less access to options for recreational physical activity, both in their neighbourhood and in other parts of the city, due to a lack of transport and of gender-inclusive and convenient spaces, as well as safety issues.

 

Since COVID-19, awareness of the need to develop and implement solutions in these neighbourhoods and to address barriers for the most vulnerable groups has increased. However, while case studies of participatory planning in this field have been documented, they often have not been evaluated. Thus, knowledge and practice of how to sustainably engage and develop trustful and reciprocal relationships with vulnerable groups in multiple settings is lagging.

 

Evidence-based solutions for increasing physical activity exist, and are outlined in the WHO GAPPA 2018-2030. GAPPA aims to achieve a 15% relative reduction in physical inactivity in adults and adolescents by 2030. It includes 20 evidence-based actions across four domains: Active People, Active Societies, Active Environments, and Active Systems.

 

Actions to foster active people such as behavioural counselling and educational materials, instructor-led and community classes, and walking clubs increase PA and engage underserved populations and the elderly (active People).

 

For Active Societies, large-scale campaigns, such as the Stanford Heart Disease Prevention Programme, mass participation events such as the Bogota Ciclovia, traffic safety and improved street aesthetics, and training for public health and sports practitioners are supported by evidence from numerous countries across all continents.

 

In the Active Environment category, measures to create pedestrian-friendly environments, enhance access to open spaces, provide walking and biking trails, and improve road safety are effective and often cost-effective.

 

There are several examples of multi-level, multi-component means to create Active Systems such as cross-sectoral coordination mechanisms and improvement of data systems.

 

GAPPA offers a very strong basis for CITY MOVE interventions because it is comprehensive allowing a system-based approach, and because it is a Global Action plan endorsed by WHO with global targets. Besides this, the co-benefits of many GAPPA interventions e.g. green public spaces also address wider NCD determinants such as environmental risk (air pollution), social exclusion and stress. However, beyond best practices, GAPPA offers little guidance on how to select and appropriately adapt the interventions.

 

A combination of interventions at individual, social and built environment levels in one package has been demonstrated to be most effective. The GAPPA framework should be addressed using a whole-of-system approach, involving all relevant government departments and stakeholders across multiple sectors, at different levels and taking into account other developments in the context. This is however a challenge for most cities in terms of coordination, timeframes for interventions, and competing interests and policy priorities impeding implementation. There is limited guidance to support cities in adapting interventions to the local context, specifically how they combine and sequence the multiple approaches to result in efficient and effective change. This is in fact the lack of a system’s perspective on city-GAPA implementation, which would allow the analysis of the comprehensive GAPPA implementation and constraints within the city environment. While co-creation is recommended, the involvement of communities often remains tokenistic. Vulnerable groups struggling with basic needs are less likely to participate and may not find their concerns addressed. The systems approach to involving multiple sectors, considering all context layers, interactions, crucial constraints, and trade-offs and benefits for the entire city system is underdeveloped. Further, many city authorities lack robust data systems to monitor and evaluate ongoing projects. This is particularly glaring in low and. middle income countries, as most available evidence is from high-income countries. A lack of longitudinal data limits evidence about the scale and the (often long) duration necessary for interventions to have an impact.

 

The potential of cities to reduce NCD risk is underutilised. Cities are home to over half of the world’s population – expected to reach two-thirds by 2050, with 90% of this increase expected in Asia and Africa, most of which is unplanned. City environments are a key determinant of NCDs through several intersecting social, cultural and environmental factors. Cities are associated with lower physical activity, access to unhealthy diets, and overweight and obesity. Environmental factors in cities such as ambient and household air pollution, exposure to chemicals and occupational risks also influence NCDs including cardiovascular disease, chronic respiratory illnesses, diabetes, and cancers. On the other hand, density, transport systems, building and street designs, and land use patterns impact NCDs through their influence on air quality, physical activity, diet, blood pressure, and obesity. However, the implementation of health-promoting interventions is slow and unequal, disfavouring low and middle income. countries and under-resourced neighbourhoods. Cities are thus both a threat to health and a potential enabler of change. Given the untapped potential of cities to promote physical activity, CITY MOVE focuses on adapting GAPPA to the city-level, city-GAPPA.

 

Cities across continents face different challenges. In addition to the specific local context needs, there are regional and cultural differences in barriers and approaches to promotion. Cities with fast-growing populations and poor planning face acute challenges; barriers to physical activity in many African cities for instance relate to road safety and connectivity. In emergent cities – many in Latin America – with a high projected ratio of economic growth to population growth, there is momentum to invest and adapt city planning to its fast-growing population, but challenges relate to integrating projects into city policies, which are also bound by national policy contexts and regulations. Many cities in central and eastern Europe have ageing populations and struggle to address their needs for health promotion, care, and how to promote independent lifestyles.

 

CITY-MOVE aims to accelerate and support action for physical activity at the city level in six cities across three continents: Europe (Antwerp, Ljubljana, and Rotterdam), Africa (Kampala) and Latin America (Bogota and Lima), to learn from cities in different phases and in diverse cultural and macro-economic contexts.

The GAPPA evidence-based actions