Stakeholder perspectives on adapting and disseminating Ghana’s physical activity guidelines: a qualitative study

Ghana, as well as other developing countries across the world, is facing the public health “double burden” of both communicable and chronic diseases [1‐4]. Chronic disease prevalence is on the rise as urbanization and sedentary work increase [5‐8]. The benefits of physical activity as a modifiable risk factor in chronic disease prevention have been well established [9‐11]. However, rates of physical activity in Ghana have decreased across the life span, with most Ghanaian youth not meeting physical activity recommendations [12, 13], and women, older adults, and those living in urban areas less active than their peers [5, 7, 8, 14, 15]. Physical activity promotion efforts are necessary to address the developing world’s new public health challenge and combat the rise in chronic disease [16, 17].

To respond to the need for physical activity promotion, Ghana’s Ministry of Health (MOH) developed physical activity guidelines in 2009 as part of the World Health Organization (WHO) Global Strategy on Diet, Physical Activity, and Health, written with a goal of assisting WHO member states with developing a national physical activity plan [6, 17]. As recommended by the WHO, the guidelines align with the 1996 Report of the US Surgeon General on Physical Activity and the National Institutes of Health Consensus Development Panel, and recommend that adults engage in 150 min of moderate-intensity aerobic activity (or 75 min of vigorous-intensity aerobic activity, or an equivalent combination of both) and two sessions of muscle-strengthening activities (targeting major muscle groups) per week, and children/adolescents engage in 1 h or more of moderate to vigorous intensity physical activity per day [6].

Establishing evidence-based national physical activity guidelines is a sound first step in developing implementation plans [18], communication strategies, and evidence-based interventions. However, across countries, there is a well-documented gap in translating research findings into improved public health, and moving physical activity policy to practice is no exception [19‐24]. Dissemination strategies (i.e., targeted approaches to spread interventions to specific audiences) [25] are needed to package and communicate the guidelines to both public health practitioners and the public. If guidelines are not communicated to the public, they may not be aware of the benefits of physical activity, recommended types and amounts, and how to achieve them.

When policies do reach public health practitioners and community members, for messages to be relatable, the policies need be to culturally appropriate. Adapting health promotion interventions (programs, policies, or practices) for new settings is crucial to enhance cultural appropriateness [26‐29]. Without images, language, examples, or other cultural features that are relevant, policies may fail to reach the target audience or be ineffective [30, 31]. The recommended process for scaling-out [32] interventions to new delivery systems and populations is: assessing priority population needs, determining necessary changes to the intervention, consulting experts, adapting, and then implementing and evaluating the adapted intervention [33].

Evidence suggests that Ghana’s physical activity guidelines have not been disseminated to end users, nor adapted for cultural appropriateness. A study on older Ghanaian adults’ perceptions of physical activity found that participants were not familiar with the MOH physical activity guidelines or how to meet them (e.g., what types of exercise counts as strength training or as moderate intensity aerobic activity) [34]. At the organizational level, no published research has been found on the implementation of physical activity programs or policies developed based on the guidelines in the 12 years since they have been published, which suggests a lack of dissemination to public health practitioners and policy makers.

Additionally, the MOH physical activity guidelines may not be culturally appropriate. As the MOH physical activity guidelines were adapted from United States-based recommendation, the guidelines include activities such as swimming and ballroom dancing as examples of moderate to vigorous level aerobic activity [6]. In previous research, older Ghanaian adults were queried about preferred types of physical activity, and reported that these are not activities they engage in (e.g., “we don’t know how to swim, we live here, but we don’t know how to swim”) [34]. Rather, the most common types of recommended aerobic physical activities among these older adults were walking, dancing, jumping/skipping rope, jogging, and team sports [34]. Literature on preferred types of physical activity in Ghana is sparse, with one other study reporting preferences for dancing, group classes at the gym, and walking among adult women in Accra, Ghana’s largest urban area [35]. Thus, there is a need to determine culturally appropriate physical activities across the life span throughout Ghana.

Taken together, to improve compliance with national physical activity guidelines, these guidelines need to be disseminated to target populations of delivery agents (to eventually be disseminated to end users) and adapted to include culturally appropriate physical activities as relevant examples. To understand why the MOH guidelines were not disseminated to end users and what example activities should be included, the purpose of this study was to investigate stakeholder perspectives of 1) dissemination of the physical activity guidelines through Ghana Health Service (the implementation arm of the MOH) and 2) culturally appropriate physical activities across the life span. For the purpose of this study, we draw upon implementation science literature on adaptation, and operationalize "culturally appropriate" as relevant to the priority population and local conditions [26‐29].

This study investigated stakeholder perceptions of physical activity guidelines dissemination and culturally appropriate physical activities. The participants suggested physical activities and explained barriers, facilitators, and personal beliefs around physical activity. Additionally, the health workers interviewed shared meaning units related not only to challenges disseminating the physical activity guidelines, but also to implementing them. These results shared here can be useful in developing future versions of physical activity guidelines in Ghana along with dissemination and implementation strategies.

Participants primarily suggested aerobic activities for inclusion in the guidelines. These included walking or jogging, football, and dancing, which have been reported as common activities for Ghanaian adults and older adults in other research [34, 35]. Interestingly, although participants in other studies shared that they do not swim [34], swimming was suggested as an activity for adults and children, although it was also mentioned that the built environment does not include access to swimming facilities: “For swimming, because we do not have the facilities, it is always not available in most areas” and “but we cannot compare ourselves to those who have the swimming pool and other swimming infrastructure.” Participants also mentioned bicycling as a suggested activity and mentioned that there is a need for bicycles (“They will need bicycle. The people in my hometown need bicycle to do exercise”) and bicycle infrastructure (“bicycle trails close to home or workplace.”). While improving the built environment to facilitate more physical activities could increase access and physical activity levels, including example activities in the physical activity guidelines that most Ghanaians currently have access to may be a better strategy for increasing activity levels.

For example, traditional games were suggested as appropriate physical activities across the life span. These included ampe (a jumping game), antowankyire (a circular chase game), chaskele (a bat and ball game), and pilolo (a hide and seek game) [43, 44]. As participants mentioned the perceived healthfulness and positive perceptions of traditional games (“So, I think our local ones [traditional games] will be too healthful though I can’t mention all, but what we were doing about 40 years ago, I think we should go back to it.”), they are likely to have high acceptability and appropriateness [45] among community members. Related, there is recent interest in ampe both as a competitive sport as well as an obesity prevention intervention, with a recent study finding that a four-week ampe exercise program had positive effects on youths' body weight, blood pressure, and heart rate [43]. Including familiar, traditional activities in the guidelines (rather than unfamiliar activities common in other countries) could improve understanding and uptake.

While the focus group and interview respondents primarily discussed aerobic physical activities, they also mentioned two strength training activities – body weight exercise and weight lifting – for adults, but not for older adults. Daily chores were suggested across age groups (e.g., “scrubbing,” “cleaning their room”), as was stretching for older adults. These suggestions of light-intensity physical activities (rather than moderate to vigorous-intensity activities) and a focus on aerobic rather than strength training are similar to other research findings [34, 35]. More efforts are needed to provide education and clarification on types of physical activity and intensity levels to achieve disease-preventing benefits. As well, based on the activities suggested by participants, it may be useful to discuss sample physical activities in terms of domains, as described in the WHO’s Global Action Plan on Physical Activity [46]. These domains include work (including domestic work), travel (walking and cycling), and recreation (including sports), which can be combined to meet physical activity guidelines [46].

Concerning physical activity perceptions, participants believed in the benefits of physical activity, but had concerns about individual abilities that may limit physical activity participation. There were also concerns about injuries due to exercise – from youth through older adults. In addition, many of the suggested physical activities were described as “for girls” or “for boys” (e.g., “[I recommend football] mainly for boys.”); these gender perceptions may limit the physical activities perceived as available – especially for females. More work is needed to understand cultural factors and ensure that future physical activity policies clarify the appropriateness of physical activity across the life span, for all genders, and including all domains. This aligns with the WHO’s Global Action Plan on Physical Activity’s recommendation to improve access to physical activities “that are culturally appropriate and for people of all ages and abilities” [46].

Finally, lack of time was viewed as a barrier to physical activity in both adults and youth, with work and school schedules both preventing regular physical activity. Future versions of the physical activity guidelines could include partnering with school and employment sectors to implement physical activity policies, as was suggested by some respondents: … “sometimes when you go for workshops there are motility break where you can walk around.” These policies could pair well with improvements in the built environment to facilitate physical activity as a form of active transportation (to and from work or school) as well as increase the availability of recreational facilities (e.g., football pitches) for recreation during leisure time.

Regarding dissemination, the interviewees were largely unaware of the physical activity guidelines. Those who were familiar with the guidelines shared that they had not used them and relayed difficulties in using them. However, respondents believed that the physical activity guidelines would be compatible with current programs and policies. As for dissemination sources, respondents typically learned of new interventions from a variety of written materials. Packaging the physical activity guidelines into user-friendly, accessible publications [47] - disseminated online and through standard trainings - should be considered. Lastly, participants noted that the physical activity guidelines were developed in 2009 and would likely need to be updated prior to future implementation and dissemination efforts.

While the goal of the study was to understand dissemination of the physical activity guidelines (i.e., the targeted spread of information about an interventions), health worker participants also shared their perceptions of factors and strategies related to implementation (i.e., putting an intervention to use) [23, 25]. Leadership engagement and stakeholders at multiple levels – from community members and volunteers to regional and district directors – were considered important for disseminating and implementing new policies, and could be targeted for future dissemination and implementation interventions. Participants shared that other interventions may receive higher relative priority than physical activity promotion. This “double burden” of addressing both communicable and chronic diseases may result in government resources allocated to communicable disease prevention and management rather than physical activity promotion, as other researchers have noted that health care expenditure in Ghana disproportionately prioritizes communicable diseases [4, 48]. Related, some of the health workers also shared that their focus was on nutrition education rather than physical activity. Nutrition education may be a more natural focus area than physical activity promotion, as nutrition educators were already in place to address undernutrition and could shift efforts to overnutrition [48]. This focus area could be leveraged by better integrating physical activity promotion, as suggested in the WHO Global Strategy [17]. Finally, respondents suggested implementation strategies including creating an implementation plan and involving partner organizations.

The dissemination and implementation challenges discussed here are not uncommon to national physical activity guidelines [49‐52]. Across multiple countries, PA guidelines typically lack implementation strategies; dissemination strategies are more often included, but are not usually evaluated [50, 52]. With the lack of strategic dissemination efforts, passive diffusion tends to occur, resulting in incomplete and inaccurate conveyance of national guidelines [53]. The most effective dissemination and implementation strategies are unknown [49, 50], and greater efforts are needed to identify, adapt, and test strategies to build the evidence on effective strategies in community (vs. clinical) settings (Harden SM, Balis LE, Houghtaling B, Powell B: Implementation strategies in community settings: an introduction to the Expert Recommendations for Implementing Change (ERIC) Compilation, submitted) and improve the overall public health impact of national physical activity guidelines.

The goals of this study were to investigate culturally appropriate physical activities and dissemination of Ghana’s physical activity guidelines. Results suggest that guidelines should include familiar activities such as traditional games and clarify the appropriateness of physical activity across the life span and for all genders. The results also suggest that public health workers within GHS experiences challenges in disseminating the physical activity guidelines. Overall, a policy to practice gap remains, with the public largely unaware of and failing to meet guidelines [51]. Adapting and disseminating physical activity guidelines – and eventually, implementing programs based on these guidelines - is a necessary step in increasing physical activity levels and preventing chronic diseases.