BARRIERS TO IMPLEMENTATION OF ACADEMIA DA SAÚDE PROGRAM IN SANTA CATARINA BARREIRAS PARA O FUNCIONAMENTO DO PROGRAMA ACADEMIA DA SAÚDE EM SANTA CATARINA

The Brazilian Ministry of Health created the Academia da Saúde Program (ASP) to contribute to promoting health through the implementation of units for guidance on bodily practices, physical activity and leisure, with a healthy lifestyle as intended outcome. The objective of this study was to identify the perception of physical activity program managers about barriers to the operation of ASP units in Santa Catarina (SC). A cross-sectional study was conducted with 26 managers (61.5% women) of physical activity programs. Information was collected by means of a questionnaire designed for assessing interventions aimed at promoting physical activity in Primary Health Care. Descriptive statistics (mean, standard deviation, absolute and relative frequency) was used for data analysis. Results evidenced as main barriers lack of human resources, lack of support from heads, lack of material conditions, facilities and equipment, as well as lack of standardized instruments for evaluation of actions. It is concluded that organizational, infrastructure and human resources barriers are present in the routine of ASP actions in SC.


Introduction
Exercising regularly is associated with better health conditions and quality of life 1 . Promoting an active behavior is a priority of the strategic action plan for handling Noncommunicable Chronic Diseases in Brazil between 2011 and 2022 2 .
To do so, among the actions of the National Policy for Health Promotion (PNPS), the Brazilian Ministry of Health created in 2011 the Academia da Saúde Program hereafter referred to by its initials in English -ASP -, within the scope of the Brazilian Unified Health System (SUS), through Decree No 719, with the aim of contributing to promoting the population's health from the implementation of units with infrastructure, equipment and qualified personnel for guidance on bodily practices, physical activity and leisure, with healthy lifestyles as intended outcome 3 . As of 2013, the ASP is established as a point of attention that complements and boosts individual and collective assistance actions in primary health care 3 .
The ASP composes a public policy whose process of building units or implementing actions has reached 2,849 health municipal secretariats in 2016, which received the program and now count with 856 units operating in the country 4 . Bearing in mind that SUS principles and health policies propose the reorganization of actions aimed at interdisciplinarity 5,6 , it becomes important to investigate the operation of the program units, in addition to barriers found in them.
Programs similar to "Academia da Cidade", in the states of Pernambuco and Sergipe, have shown evidence based on: population inquiries about the association between participation in programs and levels of physical activity; observation of public squares, parks and other areas with and without program actions; inquiries with professionals, users and nonusers; and historical evaluation 7-9. In 2016, Santa Catarina had 124 health municipal secretariats with built ASP units or something similar, 45 of which were operating 10 . It was the only state in the South region to have 100% of participation, as reported by monitoring data on the program this year, being among the six states in the country to have achieved that 4 , reason why it deserves to be investigated. Tracking the ASP allows understanding the implementation process of its actions, which may involve different contexts of great importance such as: planning, which allows evaluating the program positive aspects and difficulties, considering the influences of the environment in which it is inserted, enabling the formulation of strategies and goals to be implemented 11 ; operationalization, means by which previously planned tasks are put into practice, and something that depends directly on good leadership, motivation and communication 12 ; and evaluation, herein understood as ongoing and routine follow-up on program execution, which can be carried out by different indicators, allowing managers to see the program performance and check if goals are being reached 13 .
Although the ASP has been established in Brazil since 2011 and is highlighted as an important element to expand the scope of actions of the National Policy for Health Promotion 6 , up to the present moment the literature has no studies describing barriers perceived by unit managers to the implementation of actions within this program. Evidence about barriers related to the ASP found in the literature has focused on the participation of users in physical activity programs and on healthy lifestyles 10,14 .
In terms of ASP evaluation, the perception of managers about performance related to reached goals is crucial 13 . Thus, it is worth stressing the importance of investigating the perception of physical activity program managers when it comes to barriers found to the operation of planning, operationalization and evaluation actions targeting the ASP in Santa Catarina so that new strategies and actions are taken.
Thus, this study aimed to identify the perception of physical activity program managers about barriers to the implementation of planning, operationalization and evaluation actions concerning Academia da Saúde Program units in Santa Catarina that have a direct impact on their operation.

Study Design
This is a cross-sectional study with quantitative data analysis. It derives from a research titled "Evaluation of programs for physical activity promotion in the state of Santa Catarina" (APAF), conducted by the Gerontology Laboratory (LAGER) of the Center for Health and Sports Science (CEFID), Santa Catarina State University (UDESC), with the support of Santa Catarina's Health Secretariat. All study procedures were approved by UDESC's Ethics Committee on Research Involving Humans (protocol CAAE: 7414515.0.0000.0118)

Study Location
The study was carried out in the state of Santa Catarina, Brazil, which is currently composed of 295 municipalities and has as capital de city of Florianópolis 15 . The state is divided into six political-administrative meso-regions: Great Florianópolis (21 municipalities), Northern Santa Catarina (26 municipalities), Western Santa Catarina (118 municipalities), Highlands (30 municipalities), Southern Santa Catarina (46 municipalities), and Vale do Itajaí (54 municipalities) 15 . It is worth highlighting that, in 2016, Santa Catarina was the only state in the southern region and one of the six Brazilian states to have comprehensively monitored the ASP 4 .

Population and Sample
The study population was made up of managers of physical activity programs who worked at Health Municipal Secretariats (SMS) of the 295 municipalities in the state. For their selection, the first step was sending electronic documents and correspondence to the 295 Health Municipal Secretaries of Santa Catarina, inviting them to participate in the research and answer a questionnaire, in which one of the questions was about the development of physical activity programs by the secretariats. A total of 146 out of the 295 secretaries accepted to participate and answered positively to having physical activity programs.
For a representative sample of physical activity program managers, sampling calculation was performed with confidence interval of 95%, error margin of 5%, and heterogeneity level of 50%, according to equation proposed by Bartlett et al. 16 , resulting in 128 managers. For participation in the present study, as inclusion criteria, the physical activity program managers should be working at ASP units for at least six months. Afterwards, the 128 SMS managers were contacted by phone and e-mail, 26 of which met the inclusion criteria, accepted to participate in the research and answered the study questionnaire, thus composing the study sample; they were distributed in the political-administrative mesoregions of the state as follows: 12 in Western Santa Catarina, two in Northern Santa Catarina, four in Vale do Itajaí, four in the Highlands, and four in Southern Santa Catarina.

Data Collection Instrument
The instrument for data collection was based on a few questions from the questionnaire designed for evaluating interventions aimed at promoting physical activity in primary health care (coordinator version) of Projeto SUS+Ativo, developed by the Lifestyle and Health Research Group of Pernambuco University 17 . Information covering sociodemographic conditions as to sex (male and female) and marital status (single, married and divorced) was collected, in addition to socioeconomic information as to income (in minimum wages), professional training field (physical education, nursing, administration and physiotherapy), type of postgraduate program concluded or in progress (specialization, residency and master's) and employment relationship with the health municipal secretariat (permanent and temporary/commissioned). The managers were also asked about the main reasons that have hindered the conduction of planning, operation/service actions for program users, as well as the main barriers to monitoring and evaluation (yes or no). Population data and human development indexes (HDI) of Santa Catarina's municipalities were used as well, provided by the IBGE 18,19 and PNUD 20 .

Data Collection
For data collection, the 26 managers who worked at ASP units were contacted by phone, e-mail and correspondence. First, they were invited by phone to participate in the research. After acceptance, they were requested to sign a free and informed consent form (via e-mail). Right after that, they were e-mailed the questionnaire in Google Forms® format for filling. This step was carried out from June to September 2016 by researchers with prior training. A period of 15 days was set for completion. A maximum of 7 contact attempts was made for collection of the managers' answers.

Study Variables
Barriers to the operation of the units were presented as main variables; the operation/service for program users, as well as monitoring and evaluation, were presented as the most relevant reasons that hindered the conduction of planning actions. They were evaluated dichotomically (yes or no), indicating presence or absence of barrier.
Moreover, the study considered sociodemographic characteristics, such as sex (male and female) and marital status (single, married and divorced), in addition to socioeconomic data, such as income (1-2, 3-4 and 5-10 minimum wages), professional training field (physical education, nursing, administration and physiotherapy), type of postgraduate program concluded or in progress (specialization, residency and master's), and employment relationship with the health municipal secretariat (permanent and temporary/commissioned).

Statistical Analysis
Data generated from the filling of the Google Forms® questionnaire were transferred to a Microsoft Excel 2016® spreadsheet and then imported into statistical software IBM SPSS®, version 20.0, for further descriptive statistics (mean, standard deviation, absolute and relative frequencies).

Results
The study had the participation of 26 managers (61.5% women) aged on average 33.7 years old (SD ± 7.1 years old). A total of 46.2% worked at units located in Western Santa Catarina, and 80.99% in municipalities with up to 20,000 inhabitants. As for Human Development Index (HDI), 76.9% of the evaluated municipalities scored high 20 . About academic background, only one manager did not have a college degree, while 76.9% completed at least one postgraduate course. Most managers had degrees in Physical Education (50%), and only one had no training in the health field.
When it comes to employment relationship with the Health Municipal Secretariat, 42.3% of them were permanent workers, and 57.7% had temporary or commissioned positions. The manager who had been working for the longest time in the Brazilian Unified Health System was 21 years at the job, and the one with the shortest service time had only eight months (Table 1). Concerning barriers to planning of actions at the units, the managers reported as most frequent: lack of human resources (26.9%) and lack of support from heads (19.2%). For operationalization, the most frequently mentioned barriers were lack of material conditions (26.9%), lack of support from heads (19.2%), and inadequate facilities (19.2%). As for evaluation, the study participants referred to lack of standardized instruments (23.0%) and lack of human resources (23.0%) as main barriers. Overall, 42.3% of the managers reported the inexistence of barriers to actions at their respective units, 30.8% reported no barriers to planning, 50% believed that there were no barriers to operationalization, while 46.2% did not refer to barriers to evaluation of actions at their units ( Table 2).

Discussion
The main results of this study reveal that a significant portion of the interviewed managers do not perceive any barrier to the operation of their units. The main barriers highlighted were lack of human resources, lack of support from heads, lack of material conditions, facilities and equipment, as well as lack of standardized instruments for evaluation of actions. These issues suggest important factors that need to be considered so that the units have conditions to reach their goals and potential for service within primary health care. The ASP was created with a focus on priority actions for physical activity promotion; however, its reformulation in 2013 expanded its scope of activity, when its goal became the promotion of bodily practices and physical activity, healthy diet, healthy lifestyles, production of care, and others, by means of actions that are culturally inserted and adapted to local territories 21 . Thus, identifying barriers that may limit the ability to reach this goal may be important for a greater effectiveness of the program, as well as its restructuration.
Among the barriers referred to by the ASP managers, lack of human resources, that is, of professionals qualified to work at the units, was one of the most frequently mentioned points (26.9%). There are several hindrances when it comes to training of qualified professionals because a set of variables is necessary to link theory and practice 22 . In a study conducted in a large city in the state of São Paulo, which aimed to understand the perceptions of SUS users about the service provided in primary health care, the participants reported lack of professionals and high turnover at health units 23 . Thus, the formation of qualified and engaged human resources is of uttermost importance for the development of public policies and has been a concern for planners in the health field. Duly trained and committed professionals can ensure the population with quality service, in compliance with the principles that guide the SUS 24,25 . Since 2015, the Brazilian Ministry of Health has promoting the PNPS implementation course, focused on the ASP, which, long term, may help in the application of management and planning to practice scenarios.
Lack of support from heads was also reported as a major barrier to the operation of ASP units, being prevalent in the three contexts -planning, operationalization and evaluation. This barrier may be related to employment relationship status, since more than half of the participants (57.7%) holds a temporary or commissioned position. The financial stability of permanent employees (42.3%) perhaps improves their performance at the job, favoring collective interests rather than their own 26 . Thus, because most managers in this study had temporary or commissioned jobs, the development of management actions for the program may be compromised and prevent the ASP from advancing, considering that hiring without public tender limits the continuity of proposals and ties with communities, which may cause a sensation of not belonging to that reality on the part of professionals, thus hindering the implementation of actions at the units.
Another factor that has contributed as encouragement refers to interpersonal relationships. Bonding is of extreme importance for people and may influence an individual's life when it comes to their physical, mental and behavioral health 27 . These findings were revealed in a study that directly associated job satisfaction with levels of social support at work and concluded that those employees with high levels of support were approximately four times more satisfied with their jobs 28 . Thus, lack of support in the work environment may directly affect people's performance. Corroborating with these results, ASP managers in Recife reported poor articulation between professionals from the program and professionals from the Family Health Support Group 29 . For an adequate implementation of the ASP, managers should promote a multiprofessional integration, articulating several actors, such as varied professional categories and the community, in planning, execution and evaluation actions within the program.
The operationalization of ASP actions had many barriers reported, especially those related to lack of material conditions, facilities and equipment for activities. Results from the ASP tracking report, of 2015, show that only 9.9% of units in the south of the country receive municipal funds to purchase permanent material, that is, units are oftentimes limited to provide a wide scope of actions due to lack of supplies 10 .
Another aspect to consider is Santa Catarina's climate, which is sub-tropical, with distinct seasons, warm summers and cold winters, and these extreme weather conditions may compromise users' attendance and the good operation of the ASP. In the present study, inadequate state of facilities was another barrier with a considerable number of mentions among the managers as to the operationalization of actions at the units (19.2%). A study approaching organizational barriers and facilitators of Physical Activity programs within the SUS argues that lack of proper spaces is the great barrier to the development and execution of initiatives for Physical Activity promotion 30 ; another study conducted with users and monitors of the City Gym program in Belo Horizonte reported the need for improving the equipment 31 . Ferreira et al. 32 consider that the structures provided by the Ministry of Health are insufficient, as to both its physical space and functionality. Thus, it is evident that the physical spaces and facilities of the ASP must be improved and take into account the weather conditions of the location.
Still another barrier was lack of standardized instruments to evaluate ASP actions (23.0%). Standardized methodologies for evaluation of Physical Activity programs may help develop them, especially if they are governmental. These methodologies may help direct interventions to more efficient actions, as well as spare public expenses 33 . Conducted studies allow identifying distinctions, oftentimes conflicting, of concepts that are fundamental to evaluation, with operational repercussions, and suggest an in-depth understanding of the notions of efficiency, efficacy and effectiveness in the evaluation of public policies and, correlatively, of results, effects, changes and impacts 34,35 . At another level, this matter is also about evaluation priorities to be considered as being of interest to physical activity programs. The use of standardized methodologies creates an evaluation standard for managers, making the identification of variables a common language; otherwise, they may be forgotten or handled incorrectly 33 . There should be a greater articulation between the federal, state and municipal governments so that the Ministry of Health policies and guidelines reach SUS users in their everyday routine.
This study has some limitations to be considered, such as contact by phone and selfcompleted questionnaires; the comprehension of the latter by the managers may be influenced by subjectivity. With some guidance on filling, the understanding of the instrument by the managers could be more aligned. However, it is difficult to contact coordinators due to their assignments and the large territorial area of the state, which makes another data collection mode not viable. The sample accounts for 40% of all units operating in Santa Catarina in 2016, so not all managers of units in Santa Catarina are represented; however, managers from different regions and different city sizes were included, which may improve the distribution of the investigated group.

Conclusion
In general, the most perceived barriers were lack of human resources and lack of standardized instruments for evaluation of actions. A significant number of managers did not perceive any barrier, be it in planning, operationalization or evaluation contexts. This study may be useful for cities that will implement the ASP in the future to consider the barriers herein presented in order to minimize and solve problems that may exist, and so that the Program has more resources for a good consolidation in the Brazilian primary health care scenario. Annual tracking and studies are important means to investigate other possible barriers to the ASP, requiring continuity and comprehensiveness, investigating the perception of not only the managers involved in the operation of units, but also of health municipal secretaries and users.