Agita Sao Paulo

Summary

With an emphasis on involving children, students, workers, and older adults, the Agita São Paulo Initiative encourages physical activity along with civic engagement and mental stimulation. A number of programs stem from this broad initiative, including the following: walking groups focused on social justice, where members visit nursing homes or collect recyclable material; a “walk truck” that visits neighborhoods to promote messages about the benefits of walking; walking groups and stretching classes for children, parents, and staff; an annual “24-hour walk” on World Physical Activity Day; Via Viva, which closes 4 km of the road to traffic and opens it for cyclists, walkers, and runners; Ginástica no Parque (Gymnastics in the Park), which reaches almost 6,000 people on a monthly basis; and an annual event called Agita Galera (“move crowd” or Active Community Day), held in 5,500 schools, in which children partake exercise and discuss active living. There have been a number of reported benefits for both the population’s health and the economy in Sorocaba. Between 2000 and 2004, hospitalization rates from diabetes fell by 57% and hospitalization rates for stroke fell by 50%. The World Bank reported that the program is saving $310 million USD annually in health care costs. Researchers have estimated that the Via Viva program alone has a cost-benefit of $309 USD per participant.

Keys to Success

Based in behavioral theory

Underpinning Agita São Paulo’s success is a model of behavioral change called the Transtheoretical Model. Five particular “stages of behavior change” are crucial:

1. Precontemplation (not considering the behavior),
2. Contemplation (conscious consideration of the behavior),
3. Preparation (preparation for the behavior),
4. Action (current engagement in the behavior), and
5. maintenance (sustaining the behavior).

The goal of the initiative is to encourage all people to take a step forward in this process. Under this model, sedentary people will become irregularly active; irregularly active people become regularly active; regularly active people become regularly very active; regularly very active people remain very active with a diminished risk of injury.^[1]((Victor Matsudo et al., “Promotion of Physical Activity in a Developing Country: The Agita Sao Paulo Experience,” Public Health Nutrition 5, no. 1a (2002): 253–61.)) People aren’t expected to make huge leaps forward all at once. Agita thus makes improvement an attainable goal for all.

The educational materials for Agita also consider motivational factors that determine the lasting power of health initiatives. Recognizing that “it is easier to feel changes in mood or self-esteem than to notice changes in body plasma, cholesterol or glucose,” the materials stress the social and emotional benefits of physical activity, with physical benefits acknowledged but not as heavily emphasized.^[2]

Accessible, relatable, and unintimidating

The Agita initiative has taken deliberate steps to be accessible and unimposing, particularly to lower-income Brazilians. A central focus from the beginning has been to spread the message that there are ways to be physically active that are not traditional or organized. The program’s materials have deliberately avoided terms like “fitness” and “sports,” which can create assumptions that physical activity can only be highly structured and, in many cases, costly. They opt instead for terms like “active living” and “movement,” which can feel accessible to all.^[3]

In addition to deliberate language, Agita understood the limitations that might prevent people from being more physically active. In particular, Agita recognized that a lack of time was the most commonly stated reason why people don’t increase their physical activity. In response, they worked hard to communicate that physical activity goals can be met in many small chunks of 10–15 minutes several times each day as opposed to all at once.^[4]

In addition Agita communicated that exercise can be conveniently incorporated into daily life through activities including household chores and walking to school or work.^[5]

Collaborative and inclusive

Rather than trying to act alone, Agita engaged with a wide variety of partners to strengthen its efforts and to raise its profile without needing extra funds. These efforts, as well as the funding, involved the State Secretariat of Health, partner institutions in and outside the health sector, and private business partners. Importantly, the program was careful to also focus on “intrasectorial” partnerships as well; when the support of one partner was obtained, Agita reached out to a potential competitor of that partner within its same sector (e.g., the Industry Federation and the Chamber of Commerce).^[6]

Highly visible

One of the most impressive successes of Agita has been its ability to gain recognition among its target population. A home visiting survey of 645 randomly selected São Paulo homes indicated that more than 55% of the population knew about Agita, and about half of those could communicate its main message. Notably, this awareness was well distributed among different socio-economic and educational levels.^[7]

Agita has consistently raised media attention by virtue of its “mega-events”—statewide programs focused on target audiences (workers, youth, and the elderly) that garner media coverage at no added cost to the organizers.^[8] For example, the Agita Galera (Active Community) Day was covered in some 70 state and regional newspapers and reached a potential television audience of up to 21 million people.^[9] An additional feature of these mega-events is the distribution of items such as t-shirts and hats to increase recognition of Agita and its “brand.”

The wide use of many partners has also increased the amount of free publicity, as many partner institutions have independently taken such steps as printing Agita’s messages about physical activity on paystubs, newsletters, and other company materials.^[10]

Flexibility to adapt to local contexts

Because Agita has partnerships in hundreds of municipalities, it has been designed to fit diverse social, cultural, and economic contexts throughout the state. Agita uses what it calls its “two-hats” approach, in which it can emphasize either government-driven or non-governmental efforts depending on the municipality and the needs and characteristics of its citizens. ^[11]

Agita also demonstrates flexibility with its partner institutions, avoiding rigid or binding requirements that might turn potential collaborators away. The main purpose of its partners is to increase awareness and spread the Agita message through social networks; additional contributions are welcomed but not demanded. In this way, Agita had partnered with over 300 institutions by 2002.^[12]

Medical legitimacy

Agita has earned respect for providing true health intervention rather than simply offering a public awareness campaign or an event for physical activity. For one, the organization originally tasked with Agita’s coordination was the Studies Center of the Physical Fitness Research Laboratory of São Caetano do Sul (CELAFISCS), a respected sports sciences and research institution with both national and international recognition.^[13]

In addition, Agita spread its message in the local medical community. The initiative worked with doctors to recommend “Agitol” or the “formula for active living,” physical activity that could be written in standard prescription format and given in “doses” of 10, 15, or 30 minutes at a time, once or more per day.^[14] In this way, health promotion and prevention of diabetes and obesity were incorporated into the minds and vocabularies of medical providers.

Cost Effectiveness

The direct costs of Agita are mainly paid by the State Secretariat of Health through grants ranging from $150,000 to $400,000 per year. Given that Agita targets the entire state of São Paulo, with a population of about 40 million, this represents a cost of $0.01 per year or less per citizen.^[15] By contrast, a 2005 World Bank report estimated that, by reducing sedentary time and increasing physical activity, the program saves the state of São Paulo $310 million per year in health expenses.^[16] This equates to a return on investment of between 800% and 2,000% for the state.

Ability to Inspire

There is little doubt that the Agita effort has had widespread international influence. The World Health Organization (WHO) has recognized Agita as a model for health promotion. Multiple Latin American countries, including Argentina, Colombia, Costa Rica, Ecuador, Guatemala, Mexico, Panama, Paraguay, Peru, Uruguay, and Venezuela, have modeled their own programs after Agita and, in some cases, asked the São Paulo administrators to advise these programs. Portugal has also adopted a similar model. In 2000, the Physical Activity Network of the Americas was established from these efforts, and later a global NGO known as Agita Mundo—Move For Health.^[17]

Drawbacks and Limitations

Agita is a massive initiative, with funding from and programs for an entire state with over 40 million residents. The impressive cost-effectiveness of Agita, requiring less than one US cent per resident, is exaggerated by this scale. The cost of $150,000 for 40 million people presumably can’t scale down proportionally to $1,500 for a city of 400,000. Agita is able to save by getting such extensive and widespread use from administrative costs, advertising materials, and other major program expenses.

Administrators have also acknowledged the challenge of sustaining the program and doing so in a way that does not permanently rely on government support.^[18] This may be increasingly difficult as the program matures. Excitement may wear off, making partnerships and funding harder to come by over time. The demonstrable outcomes that currently show improvements may slow, eventually being replaced by less impressive outcomes aimed at maintenance. It will be Agita’s challenge to remain relevant and engaging such that its benefits do not erode.