Discussion
This study demonstrated that a community-based walking football programme has affordable costs, considering the present socioeconomic context of the country and similar interventions in this area. This might facilitate its implementation in the community setting and be used as a tool for T2D control.
Given their well-known health benefits, interventions to increase physical activity levels across the lifespan are recommended as a public health service. However, the available evidence regarding the cost-effectiveness of physical activity interventions is limited and restricted to a short time frames, which cannot inform about their sustainability.31
Although with the current data, we cannot assume the cost-effectiveness of this intervention, the literature has consistently shown the cost-effectiveness of physical activity interventions, especially in the context of primary care and the community. Examples include walking, exercise groups, or brief exercise counselling delivered in person.32
A previous systematic review regarding the economic evaluation of physical activity interventions for T2D management found that the evidence is limited and very heterogeneous.24 However, these interventions report some economic benefits compared with the usual care, that is, are cost saving, cost effective or have cost-utility, which is encouraging for upcoming studies.15–17 19–24
In Portugal, a similar 9-month exercise programme for patients with T2D (Diabetes em Movimento) was implemented nationally and reported implementation costs in 2016.21 To understand to which extent the community-based walking football programme could be compared with Diabetes em Movimento in the Portuguese context, we updated the latter’s costs using the most recent annual consumer prices inflation indicators from the World Bank33 (online supplemental appendix A). Costs are similar, although walking football still costs more per patient. The difference in the expenses of walking football is mainly due to the pre-exercise cardiac stress tests. Hence, walking football programme may have the potential to be scaled up and be competitive with the existing community exercise programmes.
In studies from other contexts (Europe, America, Asia and Oceania continents) and perspectives (healthcare, societal, payer)—which presented the cost of exercise programmes for patients with T2D, it was found that an intervention with a lower cost ($274.21) per participant.24 From the payer’s perspective, the intervention was based on a pedometer walking programme. The intervention group had a statistically significant incremental rate of 919 steps, compared with an increment of 393 in the control group. A decrease in costs in all categories (physician, outpatient and inpatient costs) was observed in the intervention group, compared with the control group, with a difference in total costs between groups of $82.26 per participant.
Other studies from this systematic review described costs above this programme.24 The interventions and outcomes varied; some of these studies reported cost-effectiveness.24
Physical inactivity was estimated to cost $53.8 billion globally, and T2D to cost $37.6 billion to the healthcare system in 2013.8 Physical inactivity contributed to at least $13.7 billion in productivity losses and 13.4 million disability-adjusted life-years worldwide.8
Becoming physically active would be reflected in reducing working-age mortality and morbidity and increasing productivity and life satisfaction, contributing to considerable economic gains.31 For example, Portugal loses over 7.6 million working days to absenteeism and presenteeism yearly from insufficiently active workers.34 When looking at healthcare savings and increased productivity, each person who becomes physically active has an annual economic benefit of $1165.34 This estimate may be even higher among those with chronic conditions as poorly managed chronic diseases, such as T2D, are costly to the healthcare system and the economy.
A previous scientific study on walking football for patients with T2D25 showed benefits at three levels: (1) at the individual level, the programme improved individuals’ health (eg, body fat, acute effects on blood glucose and blood pressure); was perceived as being safe (considering the low rate of injuries that occurred) and fun; moreover, participants developed their skills in walking football, which can, in turn, increase the likelihood of lifelong engagement in physical activity; (2) at the interpersonal level, participants experienced support from the family, the research team and healthcare providers; they also realised that the programme was an opportunity to socialise; (3) at the institutional level, through walking football, we developed partnerships across institutions from multiple sectors, such as health, sports, education and social care, which were fundamental to implementing and scaling up the programme.
The development of environments, policies and interventions that address the determinants of physical activity at various levels is essential to increasing opportunities for physical activity within communities.35 36
Strengths and limitations
Most physical activity interventions do not report the costs of implementation and maintenance. To our knowledge, this is the first study describing the costs of a community-based walking football programme. We found that the cost of a walking football programme is competitive compared to other available community programmes. The main limitation inherent to this study is that it only calculates the direct costs of the intervention’s implementation. In future studies, other indirect costs, such as the participants’ transportation and sports equipment costs (eg, football boots), should be considered. Nevertheless, this study already provides a ground for policymakers taking decisions about the existing interventions and build up an economic evidence base around them.
The payer perspective of analysis assists decision-makers in making informed decisions about which interventions to fund and how to allocate resources. This perspective is also useful for assessing the financial impact of an intervention on the payer, helping decision-makers identify interventions that provide good value for money and that can be funded within the available budget, and ensuring that funding decisions are consistent with payer interests and that resources are used most efficiently and effectively possible.
Future studies on physical activity interventions in patients with T2D, such as walking football, can use a framework to prospectively collect implementation costs and improve economic evaluations of public health interventions,37 therefore supporting the development of public policies that stimulate the elaboration and implementation of physical activity programmes.