Examining Public Health Strategies in City Environments

Section 1: Introduction and Background

1.1 Background

Being physically inactive has become an emerging global concern, especially because it's linked to Non-Communicable Diseases (NCDs) like cardiovascular disease, diabetes, or obesity. According to Ramírez Varela et al. (2021),the onset of NCDs is a burden on health systems, particularly in Lower-and-middle-income countries (LMICs), which continue to increasingly urbanise while having struggling healthcare resources. Furthermore, Katzmarzyk et al. (2022) state that physical inactivity is one of the greatest risk factors for NCDs; its prevalence is growing, mainly in urban areas. However, the current findings in the mentioned study focus on a huge population including high-income, middle-income, and lower-income countries while analysing the impact of physical inactivity onthe prevalence of NCDs. Furthermore, the findings do not discuss specific strategies for overcoming the issue for the urban population. Thus, this essay discusses physical inactivity in LMICs in terms of reflection on global burdens such as NCDs as well as how public health strategies have mitigated these.

WHO, (2024) determined that there isa 20%-30% increased risk of death forinsufficiently active people throughout the globe.Marques et al. (2020) through a cross-sectional survey of the adolescent population in LMICs from 105 countries identify habits of poor physical healthcare and the need for improvement among women. It is determined that populations in urban setups of LMICs are more prone to NCDs related to decreased levels of physical activity due to enhanced urbanisation and a trend of sedentary life. The findings in Katzmarzyk et al. (2022), highlighted increasing levels of physical inactivity, as well as incidences of heart disease, type 2 diabetes, and obesity in countries like India, Brazil, and South Africa.

1.2 Issues identified and rationale of the study

The contributing factors to the growing problem of physical inactivity within LMICs include; urbanisation in LMICs growing very fast, wherein its resultant lifestyle supports behaviour that tends to be sedentary.According to KlepacPogrmilovic et al. (2020), the urban environment of low-middle-income countries does not seem to have features and structures that would support an active lifestyle. The mentioned study determines that urban inhabitants may increasingly rely on motorised transportation and spend a lot of time doing desk-bound work with fewer opportunities for physical activity.

The rationale for the study relies onsolving the public health crisis growing from physical inactivity in LMICs, which essentially calls for an urgent need to be addressed. The prevelance of NCDs is now becoming the principal cause of death in LMIC regions (WHO, 2024).The rapid rate of urbanisation, the changes in lifestyle patterns, and increased socio-economic inequalities are reasons for increased risk among populations in LMICs (KlepacPogrmilovic et al., 2020). Therefore, understanding the prevalence of physical inactivity and assessment of public health strategies needs further investigation.

1.3 Study aim and objectives

This essay aims to critically investigate the prevalence of physical inactivity amongst LMIC urban populations and its contribution to the global burden of NCDs. The following objectives are dedicated to achieving the stated aim of the study;

• To evaluate on global burden of physical inactivity in LMIC.
• To discuss current public health interventions combating physical inactivity in these regions, and identify gaps in those efforts.
• To review public health strategies concerning reducing physical inactivity in LMIC.
• To identify gaps in current interventions and make recommendations for the improvement of public health responses to physical inactivity in LMICs.

Section 2: Methodology

2.1 Study design

The literature review approach assists in analysing, evaluating, and summarising existing studies to determine trends and fill gaps through updated knowledge in the field (Muka et al., 2020). This study undertakes a comprehensive literature review approach to understand the impact that physical inactivity poses upon non-communicable diseases in the urban population of low and middle-income countries.

2.2 Search Strategy Literature

2.2.1 Database

The identification of relevant literature was conducted on academic databases. Among the databases utilised include PubMed, Google Scholar, and World Health Organisation (WHO) databases. These sources were chosen for their credibility and vast coverage of global health issues.

2.2.2 Search strategy

The search strategy in secondary data collection research helps the researcher follow a structured method to obtain relevant findings within the scope of the study (Gianola et al., 2023). The search in this study used filters for articles that were published in the last 6 years, from 2018 to 2024. The reason behind the choice as gathering information only on the most current data and trends assists in solving the contemporary challenges of disease. Peer-reviewed articles and reports from global health organisations were included in the scope of the search. To ensure specificity to the defined population and setting, the scope of the search included studies focusing on the urban population of LMICs.

Keywords used included combinations of phrases: "physical inactivity," "urban populations," "low- and middle-income countries," "non-communicable diseases," "public health interventions," and "global health strategies" (Appendix 1).

2.2.3 Inclusion and Exclusion Criteria

The inclusion and exclusion criteria help the researcher to sort data collected in the research ensuring delivery of main findings within the scope of the research (Mamataz et al., 2024).

Inclusion (Appendix 2)

• The information focused on physical inactivity and its link to non-communicable diseases in an urban setting.
• Addressed public health interventions or policies related to managing physical inactivity in LMICs.
• Were able to contribute empirical data or systematic reviews relating to the subject.

Exclusion

• Physical inactivity was discussed as a problem but did not associate this with NCDs or public health interventions.
• Aged over 6 years unless to contextualise current trends

2.4 Data Collection

The data collection approach for this study would follow a secondary methodology in which a literature review approach is followed. The data collection through secondary sources enables the researcher to obtain useful findings with existing studies and obtain useful findings by comparing trends of existing data (Ranta, Aarikka-Stenroos&Väisänen, 2021). The rationale behind the selection of the secondary data collection method is that it saves time for the researcher to analyse the available data and to best answer the determined research questions.

2.5 Setting of the Research Questions

• RQ1: What is the current prevalence of physical inactivity among urban populations of LMICs?
• RQ2: How are public health strategies dealing with physical inactivity in these contexts and what are their results?
• RQ3: What gaps exist in current interventions, and what alternative strategies may be proposed for reducing physical inactivity and its burden on NCDs?

2.6 Limitations of the Methodology

The secondary data collected in this study may not be uniform amongst LMICs and other differences in methods of data collection may create problems of comparison of results across regions. Furthermore, the review does not include rural populations and high-income countries which might carry different dynamics of being physically inactive.

Section 3: Results and discussion

3.1 Global burden of physical inactivity in urban low-and middle-income countries

According to van Sluijs et al. (2021),a prominent risk factor forthe global burden of deaths is prevalent due to an increasing number of Non-communicable diseases due to poor lifestyles that include physical inactivity. The findings of the mentioned study determined that the situation is most serious in the LMICs' urban populations, where lifestyle transitions driven by a rapid pace of urbanisation have favoured lifestyles with more sitting and less activity. In LMICs, increased overcrowding, low levels of open space, and reliance on motorised transport all lead to reduced levels of physical activity. According to Ferrari et al. (2021) Brazil, the country has begun to rapidly urbanise from being middle-income. The study conducted cross-section survey analysis that finds an increased level of inactivity in the city compared to low-income areas with inadequate recreational facilities.

Ramamoorthy, Kulothungan, and Mathur (2022)highlighted that nearly 45% of adults in urban places lack the recommended guidelines for physical activity. The global burden of NCDs due to physical inactivity has been estimated at an alert level. According to WHO, (2024), there is a link between insufficient physical activity and around 9% of all premature deaths worldwide. According to Girum et al. (2020), NCDs increased considerably, accounting for 71% of global deaths which mostly occur within the LMICs. It is analysed that the condition has a greater burden in LMICs where the dual challenge of under-resourced health systems and growing urban populations poses a problem. The inability to be active, mainly in urban regions, becomes a precipitating factor in this scenario; considering it amplifies the vulnerability already present in health inequalities among a population.

3.2. Public Health Strategies to Address Physical Inactivity in Urban LMICs

The successful approach has been building community-based programs that promote physical activity. According to Melo et al. (2023) Brazil and other Latin American countries, have developed public spaces for free under a framework of outdoor gyms and fitness classes that shape the lifestyles of people. The programs are aimed at the low-income groups of urban populations. However, Yiga et al. (2020) identified challenges faced while implementing community-based interventions in sub-Saharan Africa. The programs are mostly on a small scale, and consistent support from the government is missing. Slater, Christiana, andGustat, (2020)determined that regions of South Africa have implemented green spaces for recreation in urban areas, facilities are often in abysmal condition, and safety considerations prevent general use, especially in low-income urban settings.

Proper planning and policies on urban transport are important in encouraging physical activity, especially walking and cycling. According to Baldovino-Chiquillo et al. (2023) Bogota, Colombia, has a bike lane network where most of the large streets of the city are closed to cars and opened to pedestrians and cyclists. These initiatives have proven to be very influential in active transport as observed in the large number of cyclists and pedestrians among the city's residents. However,Tiwari et al. (2023) highlighted that in many LMICs, the promotion of active transport is hindered. The mentioned study determined that pedestrian-friendly pathways and safe cycling routes are lacking in the urban infrastructure of India. Moreover, growing dependence on motorised transport and the disorderly nature of urban traffic makes walking and cycling unappealing.

3.3. Lessons from Current Interventions

Brazil and Colombiahave shown that community-based programs could serve as a very strong vehicle for bringing physical activity to low-income communities (Melo et al., 2023; Baldovino-Chiquillo et al., 2023). Both projects demonstrate that, if infrastructure and municipal support are in place, urban residents could be very active given such an environment. However, one common problem among most LMICs is the lack of steady funding for public health interventions (Tiwari et al., 2023). Most of the community-based interventions in African countries, for example, lack steady funding that ensures continuous delivery and achieves higher coverage (Melo et al., 2023). There is also infrastructure in most cities of LMICs, which discourages being physically active. Among the issues facing the community, unsafe streets, public parks, and unmanaged transport planning are some of the reasons afflicting residents in performing active transport, as they limit the residents to walking, cycling, or performing any form of active transport. Another challenge is cultural attitudes toward exercising. In some LMICs, the value attached to exercise is low in many respects, especially in urban areas where economic activities appear to consume most of the daily time. Low-income people within these urban areas tend to focus on making money instead of undertaking physical exercises, and public health campaigns often do not find room for these socio-economic realities.

3.4. Gaps and Future Challenges

According to Assefa et al. (2022) in most LMICs, public health policies are fragmented, and different areas or cities implement their programs without a single, unified national strategy. Thisinconsistentapproach to the delivery model involving unequal access to physical activity opportunities creates a gap in the successful implementation of public healthcare strategies. Another gap includes the absence of targeted interventions for vulnerable groups (Hasan et al., 2021). Although a few initiatives managed to engage the mainstream population, there are hardly any programs designed for certain population groups like women, the elderly, and disabled persons. Many cities present different cultural as well as safety issues that discourage women from participating in outdoor physical activities, and the elderly and disabled face even higher hurdles based on inaccessible infrastructure. Lastly, Reddy et al. (2021) pointed out thatthe pace of urbanisation and technological change will further complicate the task of promoting physical activity in the foreseeable future. The people in LMICs continue to drift towards cities, motorised transport will remain a growing sector for them leading to sedentary lifestyles.

3.5. Anticipated Future Strategies

Efficient Urban Planning and Integration of Physical Activity into Health Systems

According to Duminy et al. (2021),LMIC governments should look forward to investing in developing urban settings. The development of facilities that are favourable to being physically active; the provision of safe, accessible pedestrian pathways, cycling infrastructure, and public parks can be achieved. Furthermore, Jáuregui et al. (2021), determined that in LMICs, promoting physical activity would be an integral part of routine health-care services. Healthcare professionals are the most appropriate persons to motivate patients to maintain regular physical activity through counselling and referral of patients to local programs.

Use of Digital Technology

While digital technology increases sedentary lifestyle habits, it also provides an avenue to promote and advocate for the use of physical activity. According to Owoyemi et al. (2022), smartphones and digital platforms can be used to implement exercise programs, track physical activity, and mobilise through virtual communities for active lifestyles. There is a significant opportunity for partnerships between governments/public health agencies and tech companies to develop culturally relevant, accessible digital tools that aim to promote physical activity.

Policy Advocacy and Awareness Campaigns

Promotion of physical activity and raising awareness to change societal perceptions is important. According to Ludwick et al. (2020),governments in LMICs need to mandate people to invest in national campaigns to attain active lifestyles, especially targeting young people and low-income urban populations. Emphasis must, therefore, be put on highlighting accessible approaches for people on long-term health-benefitting ways of getting physically active.

Section 4: Conclusion

It is concluded that physical inactivity has emerged as one of the greatest global health challenges that significantly contributes to the burden of NCDs. This paper has discussed the pervasiveness of physical inactivity among urban LMICs; it has reviewed the effectiveness of the existing public health approaches and found gaps and challenges that need to be filled. It was determined that urban populations also have certain barriers to physical activity that most interventions cannot overcome. It can be said that the effective combating of the global burden of NCDs associated with physical inactivity requires a joint effort from policymakers, public health officials, and communities to create an inclusive and sustainable strategy. This is crucial because the emphasis on physical activity in LMICs can help promote enhancements in health outcomes and quality of life and avoid the long-term economic burden of NCDs for health systems. There is an urgent need for concerted efforts by multiple stakeholders to address the emerging public health challenge toward healthier futures for the populations in urban settings.

Appendix

Appendix 1: Search String

Appendix 2: Search filters