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Phase I: Healthy Public Policies

Phase I addresses primary prevention of diabetes, that is, on prevention among healthy people who develop diabetes. Since type 2 diabetes is strongly linked to obesity, we focus on promoting healthy diets and physical activity.


At CEAD, we are aware that individual behaviour of people is to a great extent determined by their setting. That is why we do not carry out educational activities about diabetes risk factors, recommend weight loss or exercise. Instead, we carry out policies that modify the setting where these people live so that physical activity or healthier diets are encouraged.

This could be done, for instance, by creating safe public areas that enable exercise and provide access to healthier food in terms of price and availability. This is not a new idea, in fact, it was acknowledged in the Ottawa Charter issued after the first International Conference on Health Promotion in 1986. However, there is still a long way to go before it becomes a reality, especially in low-resource settings.


In the first phase of the CEAD Project, a range of public policies to prevent diabetes are studied in the context of low-resource settings, taking into account inequality factors such as gender, ethnic group, education and socio-economic level.  We listen to opinions on diabetes distribution and its risk factors in the population and on contextual relevance, as well as the applicability of a range of policies that can be implemented in order to improve diets and promote physical activity.


Firstly, we looked for public policies that promote physical activity or a healthy diet by modifying the environment where people live and that could be implemented by leaders at the local level (city councils, school boards, companies, etc.). These policy actions should be proposed by public health institutes or organisations such as the World Health Organisation (WHO) or the UK’s National Institute for Health and Care Excellence (NICE) and meet a number of requirements:

  1. Aim to increase physical activity or improve diet.
  2. Be focused on modifying physical or social environments (and not on modifying individual behaviour).
  3. Be implemented at the local or community level.
  4. Define a concrete action (e.g. establishing cycle lanes) rather than a more abstract general objective (e.g. encouraging active transport).
  5. Explicitly described as evidence-based, i.e. having shown good results in terms of performance and effectiveness.


The next step consists of selecting the most relevant (the extent to which the action is important in the context of the urban population in the Latin American context) and applicable (the possibility that a recommendation could be materialised or implemented in the Latin American context) policy actions from the list previously elaborated with the help of the Delphi method. This method consists of bringing together experts in different fields and contexts to give their opinion on a series of public policies in order to select the highest priority ones.

We believe it is important to have specific knowledge of the setting in which we plan to work to, first, understand the distribution of diabetes risk factors and, second, encourage action.

That is why two population surveys are carried out in Quito’s urban area and in  Esmeraldas’s rural area. The aim is to analyse the prevalence of diabetes and risk factors of chronic diseases, taking into consideration the relevance of social inequality regarding gender, age, education, and ethnic group in areas of low- and medium resources settings.

We randomly choose 720 residents of Quito’s 17D06 health district and 720 residents of Esmeraldas’s 08D02 health district.  If you are taking part in the population survey, you can see detailed information about the procedure here.

In the last part of phase I, we contextualise the public policies previously selected. We organise 5 focal groups in Quito and 5 focal groups in Esmeraldas to contextualise approximately 10 policies that can increase physical activity and encourage a healthy diet.

The discussion focuses on analysing the feasibility and applicability of the possible political actions selected in their context. Facilitators show the results of the survey and participants talk about the differences observed among the population groups (health inequality), suggest possible reasons for these differences and offer solutions. Finally, participants analyse the capacity of policies to approach health inequality in its context. All the focal groups in the study consist of participants selected by intentional sampling. There are 4 types: A. individuals with diabetes and their families; B. members of the community; C. health care professionals; and D. decision makers involved in actions that have an influence on health.