Health professionals' perspectives in exercise referral: implications for the referral process

Technology acceptance model perspective on the intention to participate in medical talents training in China

Objectives

This study seeks to investigate the willingness of medical professionals to embrace training in sports medicine integrated talents, as well as the factors that influence their decision-making process. By utilizing technology acceptance models, the objective is to gain a comprehensive understanding of this phenomenon and provide valuable recommendations to facilitate the development of proficient integration of sports and medicine (ISM) talents.

Methods

The questionnaire was developed through a comprehensive review of relevant literature and consultation with experts in the field. A cluster sampling method was employed to select medical professionals from various medical institutions in Guangxi Zhuang Autonomous Region (Guangxi) who had participated in ISM talent training. The collected data were analyzed using the AMOS structural equation model, ensuring a rigorous and systematic approach to data analysis.

Results

A total of 403 questionnaires were collected in this survey, and 8 out of the 9 research hypotheses formulated for the model variables were found to be supported. Perceived usefulness, perceived ease of use, subjective norm and training satisfaction were identified as significant factors influencing the behavioral intention of medical professionals to engage in ISM talent training (P < 0.05). The path coefficients for these factors were 0.17, 0.16, 0.31 and 0.24, respectively.

Conclusion

In order to enhance the effectiveness of training for ISM talents, it is imperative for relevant departments to collaborate and focus on improving the perceived usefulness, perceived ease of use, and training satisfaction. By doing so, we can effectively harness the subjective initiative of medical professionals, thereby increasing their willingness to participate in training programs. This, in turn, will contribute to the cultivation of "high-quality, high-level" ISM talents that are essential for the betterment of society.

Factors influencing social prescribing initiatives: a systematic review of qualitative evidence

AIMS

Social prescribing is a growing health policy agenda to improve the quality and effectiveness of health systems. However, systematically collected knowledge on factors influencing the effective implementation of SP is scarce. A systematic review was conducted to identify and categorize factors influencing social prescribing initiatives.

METHODS

A search of three electronic databases (PubMed, Scopus, and ISI Web of Knowledge) was carried out to retrieve studies from inception to May 2022, supplemented by grey literature searching and snowballing of the relevant references. The inclusion criteria were original empirical research, qualitative data collection, and a description of factors affecting social prescribing initiatives. Study quality was evaluated using the Critical Appraisal Skills Programme tool. We categorized the results of individual studies using a narrative approach.

RESULTS

A total of 23 studies were included for analysis. Along with patient-related factors (patient-centeredness, clinical complexity, perception, knowledge), three main settings of social prescribing initiatives (including healthcare providers, link workers, and voluntary and community sectors) are affected by (1) individual characteristics (knowledge, perception, skill mix); (2) interpersonal relations (collaboration, trust, feedback, supportive climate, follow-up, sustained connection, peer support within and across sectors); (3) organizational contingencies (resource adequacy, staffing, training, role description, continuity of support, caseload management, monitoring, affordability, accessibility, referral criteria, and tailored support); and (4) political context (national policy and guidance, stewardship, planning, cocreation, bureaucracy, economic condition, and the number of support organizations).

CONCLUSION

Many factors influencing social prescribing initiatives were identified. The results of this review can be applied by different stakeholders of social prescribing to guide development, implementation, description, and evaluation.

Promoting physical activity to patients: a scoping review of the perceptions of doctors in the United Kingdom

BACKGROUND

The physician-patient encounter presents an ideal opportunity for physical activity (PA) promotion. This review aims to (i) explore the breadth and depth of existing literature investigating doctors' perceptions of PA promotion in the United Kingdom (UK) and (ii) identify factors influencing the extent to which doctors engage in PA promotion during patient interactions.

METHODS

A five-stage scoping review methodology and the PRISMA-ScR guidance were followed: Stage 1-research questions specified; Stage 2-relevant studies identified by searching five electronic databases and manual screening of references; Stage 3-studies screened using Covidence™; Stage 4-study data extracted and charted; and Stage 5-findings from included studies were analysed, summarised and reported using (i) descriptive numerical analysis to provide insight into study characteristics and (ii) narrative summary of the evidence categorised by factors that influence doctors' engagement with PA promotion.

RESULTS

In total, 16,961 studies were screened. Nineteen studies were included in the review with most conducted in primary care focusing on the perceptions of general practitioners. Seven influencing factors were identified: knowledge and training, personal interest and PA level, time, resources, confidence, the perceived role of the doctor and patient relevance.

CONCLUSION

This review provides new evidence that historical barriers and influencing factors have a persisting impact on the ability and willingness of UK doctors to engage with PA promotion with patients. Previous efforts to address these factors would appear to have had limited success. Further intervention efforts are required to ensure more widespread and effective PA promotion to patients.

Use of the behaviour change wheel to improve everyday person-centred conversations on physical activity across healthcare

Background

An implementation gap exists between the evidence supporting physical activity in the prevention and management of long-term medical conditions and clinical practice. Person-centred conversations, i.e. focussing on the values, preferences and aspirations of each individual, are required from healthcare professionals. However, many currently lack the capability, opportunity, and motivation to have these conversations. This study uses the Behaviour Change Wheel (BCW) to inform the development of practical and educational resources to help bridge this gap.

Methods

The BCW provides a theoretical approach to enable the systematic development of behaviour change interventions. Authors followed the described eight-step process, considered results from a scoping review, consulted clinical working groups, tested and developed ideas across clinical pathways, and agreed on solutions to each stage by consensus.

Results

The behavioural diagnosis identified healthcare professionals’ initiation of person-centred conversations on physical activity at all appropriate opportunities in routine medical care as a suitable primary target for interventions. Six intervention functions and five policy categories met the APEASE criteria. We mapped 17 Behavioural Change Techniques onto BCW intervention functions to define intervention strategies.

Conclusions

This study uses the BCW to outline a coherent approach for intervention development to improve healthcare professionals’ frequency and quality of conversations on physical activity across clinical practice. Time-sensitive and role-specific resources might help healthcare professionals understand the focus of their intervention. Educational resources aimed at healthcare professionals and patients could have mutual benefit, should fit into existing care pathways and support professional development. A trusted information source with single-point access via the internet is likely to improve accessibility. Future evaluation of resources built and coded using this framework is required to establish the effectiveness of this approach and help improve understanding of what works to change conversations around physical activity in clinical practice.

Linking a peer coach physical activity intervention for older adults to a primary care referral scheme

BACKGROUND

Physical inactivity has contributed to the current prevalence of many age-related diseases, including type 2 diabetes and cardiovascular disease. Peer coach physical activity intervention are effective in increasing long term physical activity in community dwelling older adults. Linking peer coach physical activity interventions to formal care could therefore be a promising novel method to improve health in inactive older adults to a successful long-term physical activity intervention.

METHODS

We evaluated the effects of linking a peer coach physical activity intervention in Leiden, The Netherlands to primary care through an exercise referral scheme from July 2018 to April 2020. Primary care practices in the neighborhoods of three existing peer coach physical activity groups were invited to refer patients to the exercise groups. Referrals were registered at the primary care practice and participation in the peer coach groups was registered by the peer coaches of the exercise groups.

RESULTS

During the study, a total of 106 patients were referred to the peer coach groups. 5.7% of patients participated at the peer coach groups and 66.7% remained participating during the 1 year follow up. The number needed to refer for 1 long term participant was 26.5. The mean frequency of participation of the referred participants was 1.2 times a week.

CONCLUSION

Linking a peer coach physical activity intervention for older adults to a primary care referral scheme reached only a small fraction of the estimated target population. However, of the people that came to the peer coach intervention a large portion continued to participate during the entire study period. The number needed to refer to engage one older person in long term physical activity was similar to other referral schemes for lifestyle interventions. The potential benefits could be regarded proportional to the small effort needed to refer.

The Role of Physical Activity in Cancer Recovery: An Exercise Practitioner's Perspective

Less than 20% of cancer patients meet the recommended physical activity (PA) guidelines, partially due to poor knowledge and enforcement/encouragement amongst health-care professionals (HCPs). The primary aim of this study was to explore the perceptions of exercise practitioners on the role of PA and the physiological and psychological benefits to recovering cancer patients; the secondary aim was to understand the barriers and facilitators of promoting PA to cancer survivors. The third aim was to, seek the perspectives on the effectiveness of referral systems between the hospitals and PA structures. A purposive sample of five exercise practitioners' (four male and one female) with experience with cancer patients participated in a semi-structured interview (45-60 min). Interviews addressed five key topics: intervention procedures, patient well-being, patient education on PA, effectiveness of referrals from hospitals, and post-intervention PA. Interviews were transcribed verbatim and analysed via thematic analysis. The participants believed that recovering cancer patients possess a knowledge of the physiological benefits of PA, yet psychological understanding remains unknown. Social environments are key to participation in PA and most HCPs lacked knowledge/awareness of the benefits of engaging in PA. There is a need to improve HCPs knowledge of the benefits of PA, whilst providing standardised training on how PA can improve cancer patients' outcomes.

From a research trial to routine practice: stakeholders' perceptions and experiences of referrals to the National Exercise Referral Scheme (NERS) in Wales

Background

Over ten years on from a randomised controlled trial and subsequent national roll-out, the National Exercise Referral Scheme (NERS) continues to be routinely delivered in primary care across Wales, UK. Few studies have revisited effective interventions years into their delivery in routine practice to understand how implementation, and perceived effects, have been maintained over time. This study explores perceptions and experiences of referral to NERS among referrers, scheme deliverers and patients.

Methods

Individual, semi-structured interviews were conducted with 50 stakeholders: scheme referrers (n = 9); scheme deliverers (n = 22); and referred patients (n = 19). Convenience sampling techniques were used to recruit scheme referrers and purposive sampling to recruit scheme deliverers and patients. Thematic analysis was employed.

Results

Analyses resulted in five key themes; referrer characteristics, geographical disparities in referral and scheme access, reinforcements for awareness of the scheme, patient characteristics and processes and context underpinning a referral. Overall there was a high concordance of views between all three stakeholder groups and barriers and facilitators were found to be entwined within and across themes. Referral barriers persisting since the earlier trial included a lack of consultation time and a lack of referral feedback. Newly identified barriers included a lack of scheme awareness and a referral system perceived to be time intensive and disjointed. Key referral facilitators included patient self-referrals, a growing scheme reputation and promotional activities of scheme deliverers.

Conclusions

Findings provide evidence that could inform the further development of NERS and wider exercise referral schemes to ensure the referral process is timely, efficient and equitable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07266-7.

Understanding adherence of hypertensive patients in Mexico to an exercise-referral scheme for increasing physical activity

Among the strategies developed thus far for promoting physical activity (PA), exercise-referral schemes (ERs) have gained in popularity as an effective means of preventing secondary health conditions such as hypertension. However, information on the factors affecting adherence to these programs is limited. Using a mixed-methods approach, we undertook the present study to determine the factors associated with adherence to a specific ER aimed at increasing PA among the hypertensive patients in a Social Security institution in Mexico. Data were obtained through semi-structured questionnaires and interviews as well as from the clinical records of participants. For the quantitative component, multinomial regression analysis estimated the factors behind the varying levels of adherence. For the qualitative component, we performed a content analysis based on the health belief model. According to our findings, 80% of participants who began the ER exhibited high levels of adherence. Older age and being female were the key demographic characteristics of those showing increased adherence. Meanwhile, financial issues, the investment of time required, low perception of the benefits of PA, lack of confidence in being able to achieve changes in lifestyle, and a reluctance to acknowledge the seriousness of their health condition were the principal factors among those who did not join the program or exhibited low levels of adherence. Our findings can serve as a basis for designing PA interventions that take into account individual, cultural and administrative elements in their efforts to improve adherence to PA programs for those suffering from chronic conditions such as hypertension.

Tensions and opportunities in social prescribing. Developing a framework to facilitate its implementation and evaluation in primary care: a realist review

Background

Social prescribing (SP) involves linking patients in primary care with services provided by the voluntary and community sector (VCS). Despite growing interest within NHS primary care, it remains unclear how and under what circumstances SP might contribute to good practice.

Aim

To define ‘good’ practice in SP by identifying context-specific enablers and tensions. To contribute to the development of an evidence-based framework for theorising and evaluating SP within primary care.

Design & setting

Realist review of secondary data from primary care-based SP schemes.

Method

Academic articles and grey literature were searched for qualitative and quantitative evidence following the Realist And Meta-narrative Evidence Syntheses — Evolving Standards (RAMESES). Common SP practices were characterised in three settings (general practice, link workers, and community sector) using archetypes that ranged from best to worst practice.

Results

A total of 140 studies were included for analysis. Resources were identified influencing the type and potential impact of SP practices and four dimensions were outlined in which opportunities for good practice arise: 1) individual characteristics (stakeholder’s buy-in, vocation, and knowledge); 2) interpersonal relations (trustful, bidirectional, informed, supportive, and transparent and convenient interactions within and across sectors); 3) organisational contingencies (the availability of a predisposed practice culture, leadership, training opportunities, supervision, information governance, resource adequacy, accessibility, and continuity of care within organisations); and 4) policy structures (bottom-up and coherent policymaking, stable funding, and suitable monitoring strategies). Findings were synthesised in a multilevel, dynamic, and usable SP framework.

Conclusion

The realist review and resulting framework revealed that SP is not inherently advantageous. Specific individual, interpersonal, organisational, and policy resources are needed to ensure SP best practice in primary care.

The match between what is prescribed and reasons for prescribing in exercise referral schemes: a mixed method study

Background

Exercise referral schemes (ERS) aim to tackle non-communicable disease (NCD) by increasing physical activity levels through prescribed exercise. However, there is a sparsity of knowledge upon what exercises are prescribed and if they are targeted towards tackling NCD.

Method

Mixed methods were employed. Quantitative data was extracted from exercise prescription cards of 50 participants and were assessed for frequency, intensity, type and time of prescribed exercise. Descriptive measures of aggregate data are expressed as median (range: minimum-maximum). Thematic analysis of semi-structured interviews generated qualitative data on exercise referral instructors’ experiences of prescribing exercise.

Results

Thirty-eight different types of exercise were prescribed. Median prescription was 4 (1–11) exercises per session, at a moderate intensity. Participants were prescribed a median of 35 (5–70) minutes of aerobic exercise per referral session. Exercise referral instructors prescribed exercise to improve activities of daily living, promote independence and autonomy of participants, rather than explicitly targeting the referral condition.

Conclusions

Knowledge that prescribed exercises are not explicitly targeted to the referral condition provides critical information in understanding the purpose of exercise prescription. Future evaluations of ERS should be mindful of this, that is, perceived outcomes might not match up to what is being prescribed within ERS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11094-z.

Gender Differences in Uptake, Adherence and Experiences: A Longitudinal, Mixed-Methods Study of a Physical Activity Referral Scheme in Scotland, UK

Physical activity referral schemes (PARS) are implemented internationally to increase physical activity (PA), but evidence of effectiveness for population subgroups is equivocal. We examined gender differences for a Scottish PARS. This mixed-methods, concurrent longitudinal study had equal status quantitative and qualitative components. We conducted 348 telephone interviews across three time points (pre-scheme, 12 and 52 weeks). These included validated self-reported PA and exercise self-efficacy measures and open-ended questions about experiences. We recruited 136 participants, of whom 120 completed 12-week and 92 completed 52-week interviews. PARS uptake was 83.8% (114/136), and 12-week adherence for those who started was 43.0% (49/114). Living in less deprived areas was associated with better uptake (p = 0.021) and 12-week adherence (p = 0.020), and with male uptake (p = 0.024) in gender-stratified analysis. Female adherers significantly increased self-reported PA at 12 weeks (p = 0.005) but not 52 weeks. Males significantly increased exercise self-efficacy between baseline and 52 weeks (p = 0.009). Three qualitative themes and eight subthemes developed; gender perspectives, personal factors (health, social circumstances, transport and attendance benefits) and scheme factors (communication, social/staff support, individualisation and age appropriateness). Both genders valued the PARS. To increase uptake, adherence and PA, PARS should ensure timely, personalised communication, individualised, affordable PA and include mechanisms to re-engage those who disengage temporarily.

"You've Got to Pick Your Battles": A Mixed-Methods Investigation of Physical Activity Counselling and Referral within General Practice

One in four people say they would be more active if advised by a general practitioner (GP), yet 72% of GPs do not discuss physical activity (PA) with patients and 80% of GPs are unaware of the PA guidelines. The aim of this study was therefore to investigate GP perspectives on PA counselling and referral and interpret these within the context of the socio-ecological model (SEM). Fifty-six GPs completed an online survey to investigate factors influencing PA counselling and referral. Semi-structured interviews were then conducted with seven GPs to explore topics in more depth. Interview data were analysed thematically and mapped to the SEM. GPs were more likely to discuss PA with patients if they were physically active themselves (p = 0.004). Influences on PA counselling and referral were identified at the policy (provision of education, priority), organisational (feedback, e-referral), interpersonal (PA as everybody’s business, patient factors) and intrapersonal (knowledge, GP PA levels) levels of the SEM. Multi-level strategies are required to help GPs promote PA and make use of exercise referral schemes, including making PA a strategic priority, introducing systems for feedback from referrals, and involving other members of the care team in PA counselling and referral.

Connecting primary care patients to community-based physical activity: a qualitative study of health professional and patient views

Background

Inconclusive evidence supporting referrals from health professionals to gym-based exercise programmes has raised concern for the roll-out of such schemes, and highlights the importance of developing links between healthcare settings and community-based opportunities to improve physical activity (PA) levels.

Aim

This study aimed to identify methods, and explore barriers and facilitators, of connecting primary care patients with PA opportunities from the perspectives of both health professionals (HPs) and patients, using the example of jogscotland.

Design & setting

An exploratory study utilising semi-structured interviews with primary care patients (n = 14) and HPs (n = 14) from one UK NHS board was conducted.

Method

Patient and HP transcripts were analysed separately using thematic analysis. Potential methods of connection were identified. The Capability, Opportunity, Motivation, behavioural (COM-B) model and theoretical domains framework (TDF) were employed to facilitate identification of barriers and facilitators for connecting primary care to community jogscotland groups.

Results

Three methods of connecting patients to community-based groups were identified: informal passive signposting, informal active signposting, and formal referral or prescribing. Barriers and facilitators for patient connection fell into five TDF domains for HPs and two COM-B model components for patients.

Conclusion

For patients, HPs raising the topic of PA can help to justify, facilitate, and motivate action to change. The workload associated with connecting patients with community-based opportunities is central to implementation by HPs. Integrative resource solutions and social support for patients can provide a greater variety of PA options and the vital information and support for connecting with local opportunities, such as jogscotland.

Physicians' intention to provide exercise counseling to patients in Taiwan: an examination based on the Theory of Planned Behavior

Increasingly more clinical guidelines have recommended that physicians provide exercise counseling (EC) to patients to help improve their lifestyle and enhance treatment effects. However, little is known about physicians' EC intention and associated factors. This study aimed to systematically examine physicians' EC intention using the Theory of Planned Behavior (TPB). Using the TPB as a theoretical and structural framework, 27 TPB items were developed and factor-analyzed to form five factors (i.e., attitudes toward positive and negative EC outcomes, subjective norms, and perceived control over EC under facilitating and constraining conditions) with satisfactory psychometric properties. Responses from 1,006 physicians (response rate 90.5%) were analyzed using multivariate logistic regression to examine the TPB-based factors associated with greater EC intention. Physicians' favorable attitudes toward positive EC outcomes (adjusted odds ratio [AOR] 4.03) were most strongly linked to high EC intention, followed by supportive subjective norms (AOR 3.74) and high perceived control under facilitating conditions (AOR 1.64). Specifically, physicians' EC intention was related to their attitudes toward better treatment effects and gaining respect from patients because of EC, perceived support for EC from patients and senior physicians, and perceived control over EC concerning their behavioral change skills. These findings could inform EC promotion efforts in clinical settings and medical education. EC-related training should be incorporated into medical school curriculum, residency training, and continuing medical education to enhance physicians' EC-related knowledge and competence, including lifestyle management and behavioral change skills. Attention should also be paid to the role of patients and senior physicians in promoting EC.

An integrated model of exercise support for people affected by cancer: consensus through scoping

INTRODUCTION

Exercise support for people with cancer is a national priority. The purpose of this study was to identify the success factors necessary to create a model of exercise support for people affected by cancer in a large city in the north of England.

METHOD

Two groups of participants were recruited; people affected by cancer (n = 26) and professional stakeholders (n = 14) contributing to either focus groups or semi-structured interviews. Data were analysed using framework analysis.

RESULTS

Results from this study suggest that the promotion of exercise is not a priority in routine cancer care. Patients identified a lack of support and difficulty attaining information as a barrier to becoming active, emphasising a gulf between the patients' needs and the health professionals' priorities. People affected by cancer and professionals agreed that exercise was beneficial to cancer patients both during and after treatment. For an exercise pathway to be successful, key factors were identified including accessibility; tailored support; social interaction; affordability; competence of exercise delivery staff.

CONCLUSIONS

There was consensus on the importance of exercise and critical factors required to develop a sustainable, accessible and effective service. Evidence to inform the development of an exercise pathway for people affected by cancer is provided.Implications for rehabilitationExercise should be an included component of a cancer treatment plan, discussed and initiated from diagnosis.Health professionals have a responsibility to provide clear, consistent evidence-based advice on exercise.Exercise professionals must be appropriately trained in cancer rehabilitation according to National Institute for Health and care Excellence (2014).Individual assessments of exercise needs, preferences and cancer limitations will result in a bespoke plan of recommendations and support.The option of group activities has the advantage of increased social interaction, peer support and shared experiences.Available exercise/physical activity services should be accessible and affordable but may involve a modest contribution.

Health care professionals' perspectives on barriers to treatment seeking for formal health services among orphan children and adolescents with HIV/AIDS and mental distress in a rural district in central, Uganda

BACKGROUND

Little/no research has been conducted in Uganda in particular and sub-Saharan Africa in general on the health professional's perspectives on barriers to treatment seeking for formal health services among orphan children and adolescents with a double burden of HIV/AIDS and mental distress.

AIM

To explore health professionals' perspectives on barriers to treatment seeking for formal health services among orphan children and adolescents with HIV/AIDS and mental distress in Masaka, Uganda.

METHOD

Qualitative research design using key informant interviews with health service managers and staff in agencies working with children and adolescents with HIV/AIDS in Masaka district, Uganda.

RESULTS

Barriers to treatment seeking reported by health care professionals were quite enormous and are summarized under: family, individual, community and health systems level barriers. The crosscutting finding here is that the societal informal and formal systems of care had been affected by the HIV/AIDs epidemic, and, mental distress aggravates this challenge for the individuals afflicted and families affected by mental distress.

CONCLUSION

Children and adolescents with both HIV/AIDS and mental distress are vulnerable due to constraints at family, community and health systems levels. Effective public health interventions to address the double burden of HIV/AIDS and mental distress will be vital in the study communities addressing the constraints at family, community and institutional level. Public health interventions should aim at increased access and effective utilization of services for both HIV/AIDS and mental health services. Stigma reduction strategies at individual, family and community levels are also recommended.

Perceptions of Care Sport Connectors' Tasks for Strengthening the Connection Between Primary Care, Sports and Physical Activity: A Delphi Study

INTRODUCTION

Care sport connectors stimulate physical activity and facilitate collaboration between the primary care and physical activity sectors in the Netherlands. To strengthen intersectoral collaboration between the primary care and sports sectors, it is necessary to study which tasks a care sport connector must fulfil according to their own and other professionals' perceptions.

METHODS

A Delphi study was conducted with 182 professionals from the primary care, public health and physical activity sectors. Rounds 1 and 2 included questions about task perception, willingness to collaborate and expectations of care sport connectors. Rounds 3 and 4 were used to reach consensus.

RESULTS

All professions acknowledged physical activity promotion tasks, but they are not all willing to collaborate. They expect a broad range of roles from care sport connectors: informative, executive, guiding and intermediate. Care sport connectors reached consensus on two roles: informative and intermediate.

DISCUSSION

Care sport connectors have an important role in strengthening intersectoral collaboration. All the professions acknowledged a task concerning physical activity promotion and accepted a broker role. Thus, a public health mind-set seems to be present to some extent. However, challenges remain, such as the lack of willingness to collaborate among primary care professionals and sports policies not (yet) supporting intersectoral collaboration.

Process evaluation of a tailored workplace intervention designed to promote sustainable working in a rapidly changing world

Increasing numbers of people are employed in sedentary occupations, spending large amounts of time sitting at work which is detrimental to health and wellbeing. Evidence-based guidance is required to intervene to reduce sedentary behaviour, encourage physical activity and promote sustainable working. This article presents a process evaluation of a successful workplace intervention Walking Works Wonders, shown to be effective in improving health, job satisfaction and motivation (Haslam et al. 2018). In this qualitative process evaluation employees reported an increased awareness of their sedentary time and they particularly valued the monitoring of activity using pedometers. They described changes to their working and leisure time activity to accumulate more steps. Participants reported improved physiological and psychological health outcomes, improved working relations with colleagues, changes in dietary behaviour and involving their families in physical activity. The results highlight elements of the intervention that encouraged healthy and more sustainable working practices.Practitioner summary: This study provides the employees' perspective on the effective elements of a workplace intervention which encouraged physical activity and reduced sitting time. The results offer valuable insights for practitioners aiming to develop interventions to improve health and facilitate more sustainable working practices in a rapidly changing world of work.Abbreviations: BMI: body mass index; PDF: portable document format.

What approaches to social prescribing work, for whom, and in what circumstances? A realist review

The use of non-medical referral, community referral or social prescribing interventions has been proposed as a cost-effective alternative to help those with long-term conditions manage their illness and improve health and well-being. However, the evidence base for social prescribing currently lags considerably behind practice. In this paper, we explore what is known about whether different methods of social prescribing referral and supported uptake do (or do not) work. Supported by an Expert Advisory Group, we conducted a realist review in two phases. The first identified evidence specifically relating to social prescribing in order to develop programme theories in the form of 'if-then' statements, articulating how social prescribing models are expected to work. In the second phase, we aimed to clarify these processes and include broader evidence to better explain the proposed mechanisms. The first phase resulted in 109 studies contributing to the synthesis, and the second phase 34. We generated 40 statements relating to organising principles of how the referral takes place (Enrolment), is accepted (Engagement), and completing an activity (Adherence). Six of these statements were prioritised using web-based nominal group technique by our Expert Group. Studies indicate that patients are more likely to enrol if they believe the social prescription will be of benefit, the referral is presented in an acceptable way that matches their needs and expectations, and concerns elicited and addressed appropriately by the referrer. Patients are more likely to engage if the activity is both accessible and transit to the first session supported. Adherence to activity programmes can be impacted through having an activity leader who is skilled and knowledgeable or through changes in the patient's conditions or symptoms. However, the evidence base is not sufficiently developed methodologically for us to make any general inferences about effectiveness of particular models or approaches.

Correlates of physical activity counseling provided by physicians: A cross-sectional study in Eastern Province, Saudi Arabia

Background

Physical inactivity is a major health issue in Saudi Arabia (SA). Being physically active can improve overall health and prevent the risk of noncommunicable diseases and their consequences. The objective of this study was to assess the knowledge, attitudes, and practices of primary health care physicians in SA toward physical activity (PA) and identify the correlates of PA counseling provided by physicians.

Methods

A cross-sectional study was conducted in four main cities of Eastern Province, SA (Al-Khobar, Dammam, Qatif, and Safwa). A total of 147 physicians (44%) filled out self-reported surveys that were used in the assessment of the aims.

Results

Overall, 59.9% of the physicians believed that PA promotion to patients was their responsibility, and 53.7% of the physicians felt confident in their ability to provide PA counseling. However, the physicians indicated that lack of time, inadequate referral services for PA, and inadequate training in PA counseling are barriers to providing PA counseling to their patients. Only 5.4% of the physicians had excellent knowledge about PA recommendations. Female physicians were more likely to promote PA than male physicians (OR, 3.72; 95% CI, 1.10–12.58; P = .03) and more likely to assess PA in pediatric patients (OR, 2.61; 95% CI, 1.03–6.61; P = .04). Compared to other specialties, family physicians were more likely to provide general PA counseling to patients without chronic diseases (OR, 8.86; 95% CI, 1.86–42.13; P = .006). Physicians who saw fewer adult patients were more likely to systematically track/follow-up on the PA of patients (OR, 3.13; 95% CI, 1.14–8.58; P = .03) and to promote PA to pediatric patients (OR, 2.87; 95% CI, 1.37–6.00; P = .005).

Conclusions

Training medical staff in PA counseling and strengthening the health care workforce and infrastructure can help physicians improve their counseling practice.

General practitioner referrals to exercise physiologists during routine practice: A prospective study

OBJECTIVES

Physical activity is essential in the primary and secondary prevention of several chronic diseases and should be a standard component of clinical care. The aims of this study were to examine the trends and characteristics of referrals to exercise physiologists in routine care in a nationally representative sample of general practitioners (GPs) in Australia.

DESIGN

This prospective study was an analysis of Bettering the Evaluation and Care of Health (BEACH) GP data from April 2009 to March 2016.

METHODS

In total, each of 6827 randomly sampled GPs recorded details of 100 consecutive encounters (N=682,700). The rate of exercise physiologist referrals was calculated by patient and GP characteristics.

RESULTS

Over the study period, the rate at which GPs referred their patients significantly increased from 0.38 to 1.44 per 1000 encounters. Patients aged 45-64 years were most likely to be referred (1.32 per 1000 encounters). Patients from non-English-speaking backgrounds were referred at less than half the rate (0.41 per 1000) of those from English speaking backgrounds (0.96). Female GPs referred patients (1.27 per 1000 encounters) twice as often as male GPs (0.64). One-third (35.3%) of GP referrals were made for problems relating to the endocrine, nutritional and metabolic systems (e.g., obesity, diabetes mellitus); only 1.6% of referrals were made for mental health conditions.

CONCLUSIONS

Although increasing, the rate of GP referral to exercise physiologists was low and associated with patient and GP characteristics. Education of GPs about the role of exercise physiologists in the prevention and management of chronic disease is needed.

Qualitative ergonomics/human factors research in health care: Current state and future directions

The objective of this systematic review was to understand the current state of Ergonomics/Human Factors (E/HF) qualitative research in health care and to draw implications for future efforts. This systematic review identified 98 qualitative research papers published between January 2005 and August 2015 in the seven journals endorsed by the International Ergonomics Association with an impact factor over 1.0. The majority of the studies were conducted in hospitals and outpatient clinics, were focused on the work of formal health care professionals, and were classified as cognitive or organizational ergonomics. Interviews, focus groups, and observations were the most prevalent forms of data collection. Triangulation and data archiving were the dominant approaches to ensuring rigor. Few studies employed a formal approach to qualitative inquiry. Significant opportunities remain to enhance the use of qualitative research to advance systems thinking within health care.

The connection between the primary care and the physical activity sector: professionals' perceptions

BACKGROUND

To stimulate physical activity (PA) and guide primary care patients towards local PA facilities, Care Sport Connectors (CSC), to whom a broker role has been ascribed, were introduced in 2012 in the Netherlands. The aim of this study is to assess perceptions of primary care, welfare, and sport professionals towards the CSC role and the connection between the primary care and the PA sector.

METHODS

Nine focus groups were held with primary care, welfare and sport professionals within the CSC network. In these focus groups the CSC role and the connection between the sectors were discussed. Both top-down and bottom-up codes were used to analyse the focus groups.

RESULTS

Professionals ascribed three roles to the CSC: 1) broker role, 2) referral, 3) facilitator. Professionals were enthusiastic about how the current connection was established. However, barriers relating to their own sector were currently hindering the connection: primary care professionals' lack of time, money and knowledge, and the lack of suitable PA activities and instructors for the target group.

CONCLUSIONS

This study provides further insight into the CSC role and the connection between the sectors from the point of view of primary care, welfare, and sport professionals. Professionals found the CSC role promising, but barriers are currently hindering the collaboration between both sectors. More time for the CSC and changes in the way the primary care and PA sector are organized seem to be necessary to overcome the identified barriers and to make a success of the connection.

TRIAL REGISTRATION

Dutch Trial register NTR4986 . Registered 14 December 2014.

Factors influencing the introduction of physical activity interventions in primary health care: a qualitative study

BACKGROUND

The introduction of efficacious physical activity (PA) interventions in routine primary health care (PHC) is a complex process. Understanding factors influencing the process can enhance the development of successful introduction strategies.

PURPOSE

The aim of this qualitative study was to explore stakeholders' perceptions on factors influencing the introduction, i.e., adoption, implementation, and continuation, of PA interventions in PHC.

METHOD

Twenty-eight semistructured interviews were held with intervention managers, PHC advisors, intervention providers, and referring general practitioners of five PA interventions delivered in PHC. A theoretical framework on the introduction of innovations in health care was used to guide the data collection. Influencing factors were identified using thematic analysis.

RESULTS

Stakeholders reported preconditions for the introduction of PA interventions in PHC (e.g., support, resources, and networks and collaborations), in addition to characteristics of PA interventions (e.g., compatibility, flexibility, and intervention materials) and characteristics of PHC professionals (e.g., knowledge, positive attitudes, and beliefs about capabilities) perceived to enhance the introduction process. Furthermore, they proposed strategies for the development of PA interventions (e.g., involvement of future stakeholders, full development, and refinement) and strategies to introduce PA interventions in PHC (e.g., training, assistance, and reinforcement). The majority of the influencing factors were discussed specifically in relation to one or two stages.

CONCLUSION

This study presents an overview of factors that are perceived to influence the introduction of PA interventions in PHC. It underscores the importance of taking these factors into account when designing introduction strategies and of giving special attention to the distinct stages of the process.

Health professionals' perspectives on exercise referral and physical activity promotion in primary care: Findings from a process evaluation of the National Exercise Referral Scheme in Wales

BACKGROUND AND OBJECTIVES

Referring clinicians' experiences of exercise referral schemes (ERS) can provide valuable insights into their uptake. However, most qualitative studies focus on patient views only. This paper explores health professionals' perceptions of their role in promoting physical activity and experiences of a National Exercise Referral Scheme (NERS) in Wales.

DESIGN

Qualitative semi-structured group interviews.

SETTING

General practice premises.

METHODS

Nine semi-structured group interviews involving 46 health professionals were conducted on general practice premises in six local health board areas. Purposive sampling taking into account area deprivation, practice size and referral rates was employed. Interviews were transcribed verbatim and analysed using the Framework method of thematic analysis.

RESULTS

Health professionals described physical activity promotion as important, although many thought it was outside of their expertise and remit, and less important than other health promotion activities such as smoking cessation. Professionals linked decisions on whether to advise physical activity to patients to their own physical activity levels and to subjective judgements of patient motivation. While some described ERS as a holistic alternative to medication, with potential social benefits, others expressed concerns regarding their limited reach and potential to exacerbate inequalities. Barriers to referral included geographic isolation and uncertainties about patient selection criteria, medico-legal responsibilities and a lack of feedback about patient progress.

CONCLUSION

Clinicians' concerns about expertise, priority setting and time constraints should be addressed to enhance physical activity promotion in primary care. Further research is needed to fully understand decision making relating to provision of physical activity advice and use of ERS.

Collaboration of general practitioners and exercise providers in promotion of physical activity a written survey among general practitioners

BACKGROUND

General practitioners have an ideal position to motivate inactive patients to increase their physical activity. Most patients are able to exercise in regular local facilities outside the health care setting. The purpose of this study was to get insight into general practitioners perceptions and current practices regarding referral of patients to local exercise facilities. Furthermore, collaboration with exercise providers in the community was investigated, and motivators and barriers for referral.

METHODS

A written questionnaire sent to a representative random sample of 800 Dutch general practitioners. Descriptive statistics and Chi(2) tests were used.

RESULTS

All responding general practitioners (340) recommend their patients to take more exercise when necessary and 87 % say to refer patients sometimes. Limited motivation of the patient (44 %) and reduced health status (34 %) are the most mentioned barriers for advising patients to increase physical activity. When referred, most patients are send to a physical therapist (69 %) but also local exercise facilities were mentioned (54 %). The most important barrier for referring patients to local exercise activities are patients limited financial possibilities (46 %). Restricted knowledge of local exercise- or sport facilities was an additional barrier (19 %). There is little structural collaboration between general practitioners and exercise providers, but when collaboration exists general practitioners refer more often. Positive experiences of patients (67 %), affordable offers (59 %) and information of local exercise facilities (46 %) are seen as important promoting factors for referral. Although 32 % of the general practitioners think that good collaboration would be stimulating, regular meetings with sports and exercise providers were considered the least important for increasing referral (3 %).

CONCLUSIONS

Dutch physicians have a positive attitude towards stimulating physical activity but referral to local exercise facilities is low. Referral is partly hindered by restricted knowledge of local exercise facilities. Although general practitioners think that collaboration is important for physical activity promotion, it should not cost them much extra time. A coordinator with knowledge of the local situation can facilitate contacts between GP practices and sports providers.

Making the connection-factors influencing implementation of evidence supported and non-evaluated lifestyle interventions in healthcare: a multiple case study

Many implementation barriers relate to lifestyle interventions (LIs) being developed by scientists. Exploring whether implementation of non-evaluated LIs is less complicated, might offer insight how to improve the use of effective interventions. This study aimed to identify influencing factors for implementation and compare factors between evidence supported and non-evaluated LIs. Evidence-supported (n = 7) and non-evaluated LIs (n = 7) in hospitals, general practices and community care organizations were included as cases. Semi-structured interviews (n = 46) were conducted. Additionally, documents (n = 207) were collected describing intervention, implementation process, and policy. We used a stepwise approach to inductively identify factors, organize them by diffusion phase, and an existing framework. A total of 37 factors were identified. 'Dissemination' factors were mainly observed in evidence-supported LIs. 'Compatibility to existing structures' ('adoption'), 'funding' and 'connection to existing care processes' ('implementation') was factors identified in all cases. 'Quality control' and 'ongoing innovation' ('maintenance') were reported in evidence-supported interventions. In all domains of the framework factors were observed. Factors identified in this study are in line with the literature. The findings do not support the assumption that implementation of non-evaluated LIs is perceived as less complex.

Factors influencing primary health care professionals' physical activity promotion behaviors: a systematic review

BACKGROUND

Despite the promising findings related to the efficacy of interventions aimed at promoting physical activity (PA) in primary health care (PHC), the translation of these interventions to PHC practice does not always happen as desired.

PURPOSE

To help understand why efficacious PHC-based PA interventions are not effectively translated to practice, this study systematically reviewed the literature on factors influencing PHC professionals' PA promotion practices.

METHOD

Literature searches were conducted in Web of Science, PubMed, and PsycINFO for peer-reviewed articles published in English from 1990 onwards. Studies were included that met the following criteria: (1) involving PHC-based PA interventions, and (2) reporting factors influencing PHC professionals' PA promotion behaviors. Two researchers independently screened studies and extracted data. A narrative synthesis using thematic analysis was conducted to identify factors.

RESULTS

Of the 4,469 identified articles, 59 were included in the review. Factors were identified by qualitative methods, barrier/facilitator ratings, and the examination of the relationship between factors and PA promotion, and the effectiveness of introduction strategies. Many factors related to the development, delivery, and effects of the innovation, the sociopolitical and organizational culture, resources, and support, patient and PHC professional characteristics, and innovation strategies were identified as potential influences on PHC professionals' PA promotion practices. However, the lack of evidence on the relationship between factors and PA promotion indicated insufficient evidence on PA promotion determinants.

CONCLUSION

This extensive overview of potential factors can inform intervention developers and implementers on which factors may play a role when introducing PA interventions in PHC. Future research should further investigate relationships between factors and PA promotion, which should be guided by qualitative in-depth knowledge on influencing factors.

The organisation and delivery of health improvement in general practice and primary care: a scoping study

Background

This project examines the organisation and delivery of health improvement activities by and within general practice and the primary health-care team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices, how individual practices and the primary health-care team organise such public health activities, and how these contribute to health improvement. Our focus was on health promotion and ill-health prevention activities.

Aims

The aim of this scoping exercise was to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary health-care team. The key objectives were to provide an overview of the range and type of health improvement activities, identify gaps in knowledge and areas for further empirical research. Our specific research objectives were to map the range and type of health improvement activity undertaken by general practice staff and the primary health-care team based within general practice; to scope the literature on health improvement in general practice or undertaken by health-care staff based in general practice and identify gaps in the evidence base; to synthesise the literature and identify effective approaches to the delivery and organisation of health improvement interventions in a general practice setting; and to identify the priority areas for research as defined by those working in general practice.

Methods

We undertook a comprehensive search of the literature. We followed a staged selection process involving reviews of titles and abstracts. This resulted in the identification of 1140 papers for data extraction, with 658 of these papers selected for inclusion in the review, of which 347 were included in the evidence synthesis. We also undertook 45 individual and two group interviews with primary health-care staff.

Findings

Many of the research studies reviewed had some details about the type, process or location, or who provided the intervention. Generally, however, little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The range of activities suggests that general practitioners do not take a population approach but focus on individual patients. However, it is clear that many general practitioners see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Our key conclusion is that there is currently insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care more widely.

Future Research

Future research on health improvement in general practice and by the primary health-care team needs to move beyond clinical research to include delivery systems and be conducted in a primary care setting. More research needs to examine areas where there are chronic disease burdens – cancer, dementia and other disabilities of old age. Reviews should be commissioned that examine the whole prevention pathway for health problems that are managed within primary care drawing together research from general practice, pharmacy, community engagement, etc.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Effectiveness of a web-based, computer-tailored, pedometer-based physical activity intervention for adults: a cluster randomized controlled trial

BACKGROUND

Computer-tailored physical activity (PA) interventions delivered through the Internet represent a promising and appealing method to promote PA at a population level. However, personalized advice is mostly provided based on subjectively measured PA, which is not very accurate and might result in the delivery of advice that is not credible or effective. Therefore, an innovative computer-tailored PA advice was developed, based on objectively pedometer-measured PA.

OBJECTIVE

The study aim was to evaluate the effectiveness of a computer-tailored, pedometer-based PA intervention in working adults.

METHODS

Participants (≥18 years) were recruited between May and December 2012 from eight Flemish workplaces. These workplaces were allocated randomly to an intervention or control group. Intervention group participants (n=137) received (1) a booklet with information on how to increase their steps, (2) a non-blinded pedometer, and (3) an Internet link to request computer-tailored step advice. Control group participants (n=137) did not receive any of the intervention components. Self-reported and pedometer-based PA were assessed at baseline (T0), and 1 month (T1) and 3 months (T2) months post baseline. Repeated measures analyses of covariance were used to examine intervention effects for both the total sample and the at-risk sample (ie, adults not reaching 10,000 steps a day at baseline).

RESULTS

The recruitment process resulted in 274 respondents (response rate of 15.1%) who agreed to participate, of whom 190 (69.3%) belonged to the at-risk sample. Between T0 and T1 (1-month post baseline), significant intervention effects were found for participants' daily step counts in both the total sample (P=.004) and the at-risk sample (P=.001). In the at-risk sample, the intervention effects showed a daily step count increase of 1056 steps in the intervention group, compared to a decrease of 258 steps in the control group. Comparison of participants' self-reported PA revealed a significant intervention effect for time spent walking in the at-risk sample (P=.02). Intervention effects were still significant 3 months post baseline for participants' daily step counts in both the total sample (P=.03) and the at-risk sample (P=.02); however, self-reported PA differences were no longer significant.

CONCLUSIONS

A computer-tailored, pedometer-based PA intervention was effective in increasing both pedometer-based and self-reported PA levels, mainly in the at-risk participants. However, more effort should be devoted to recruit and retain participants in order to improve the public health impact of the intervention.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02080585; https://clinicaltrials.gov/ct2/show/NCT02080585 (Archived by WebCite at http://www.webcitation.org/6VvQnRQSy).

Barriers and facilitators for the implementation of primary prevention and health promotion activities in primary care: a synthesis through meta-ethnography

BACKGROUND

Evidence supports the implementation of primary prevention and health promotion (PP&HP) activities but primary care (PC) professionals show resistance to implementing these activities. The aim was to synthesize the available qualitative research on barriers and facilitators identified by PC physicians and nurses in the implementation of PP&HP in adults.

METHODS AND FINDINGS

A systematic search of three databases was conducted and supported by manual searches. The 35 articles included were translated into each other and a new interpretation of the concepts extracted was generated. The factors affecting the implementation of PP&HP activities in PC according to professionals were fitted into a five-level ecological model: intrapersonal factors, interpersonal processes, institutional factors, community factors and public policy. At the intrapersonal level we find professionals' beliefs about PP&HP, experiences, skills and knowledge, and selfconcept. The attitudes and behavior towards PP&HP of patients, specialists, practice managers and colleagues (interpersonal factors) affect the feasibility of implementing PP&HP. Institutional level: PC is perceived as well-placed to implement PP&HP but workload, lack of time and referral resources, and the predominance of the biomedical model (which prioritizes disease treatment) hamper the implementation of PP&HP. The effectiveness of financial incentives and tools such as guidelines and alarms/reminders is conditioned by professionals' attitudes to them. Community factors include patients' social and cultural characteristics (religion, financial resources, etc.), local referral resources, mass-media messages and pharmaceutical industry campaigns, and the importance given to PP&HP in the curriculum in university. Finally, policies affect the distribution of resources, thus affecting the implementation of PP&HP.

CONCLUSIONS

Research on barriers and facilitators in the implementation of PP&HP activities in multirisk management is scarce. The conceptual overview provided by this synthesis resulted in the development of practical recommendations for the design of PP&HP in PC. However, the effectiveness of these recommendations needs to be demonstrated.

Will Mobile Diabetes Education Teams (MDETs) in primary care improve patient care processes and health outcomes? Study protocol for a randomized controlled trial

BACKGROUND

There is evidence to suggest that delivery of diabetes self-management support by diabetes educators in primary care may improve patient care processes and patient clinical outcomes; however, the evaluation of such a model in primary care is nonexistent in Canada. This article describes the design for the evaluation of the implementation of Mobile Diabetes Education Teams (MDETs) in primary care settings in Canada.

METHODS/DESIGN

This study will use a non-blinded, cluster-randomized controlled trial stepped wedge design to evaluate the Mobile Diabetes Education Teams' intervention in improving patient clinical and care process outcomes. A total of 1,200 patient charts at participating primary care sites will be reviewed for data extraction. Eligible patients will be those aged ≥18, who have type 2 diabetes and a hemoglobin A1c (HbA1c) of ≥8%. Clusters (that is, primary care sites) will be randomized to the intervention and control group using a block randomization procedure within practice size as the blocking factor. A stepped wedge design will be used to sequentially roll out the intervention so that all clusters eventually receive the intervention. The time at which each cluster begins the intervention is randomized to one of the four roll out periods (0, 6, 12, and 18 months). Clusters that are randomized into the intervention later will act as the control for those receiving the intervention earlier. The primary outcome measure will be the difference in the proportion of patients who achieve the recommended HbA1c target of ≤7% between intervention and control groups. Qualitative work (in-depth interviews with primary care physicians, MDET educators and patients; and MDET educators' field notes and debriefing sessions) will be undertaken to assess the implementation process and effectiveness of the MDET intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01553266.

Mechanisms to absorb load in amputee running

BACKGROUND

We aimed to determine if a shock absorbing pylon (SAP) influenced the ground reaction force characteristics and the shock absorbing mechanisms compared to a rigid pylon (Rigid) during the loading phase in running.

OBJECTIVES

To determine if the SAP influences the mechanisms of loading compared to the Rigid condition.

STUDY DESIGN

A convenience sample of transtibial amputees participated in a laboratory-based study. The prosthetic set-up was randomly altered fd\sdsd.

METHODS

Five recreationally active male transtibial amputees age: 18-50 years; mean mass: 86.7 ± 17.5 kg; height: 1.77 ± 0.07 m) volunteered from a population-based sample. They completed a within-participant-designed study assessing a SAP and a Rigid condition during running. Kinematic and kinetic data were collected during two sessions following a one-week customization period.

RESULTS

Loading rate, peak vertical and horizontal ground reaction forces and the time to each measure along with knee and hip angular displacement, absorbing powers and work done between the SAP and Rigid conditions were not systematically affected by the prosthetic condition.

CONCLUSIONS

The effect of the SAP was minimal and inconsistent in the loading phase, with only some amputees presenting higher and others with lower values for the tested variables.

Web-based, computer-tailored, pedometer-based physical activity advice: development, dissemination through general practice, acceptability, and preliminary efficacy in a randomized controlled trial

BACKGROUND

Computer tailoring is a relatively innovative and promising physical activity intervention approach. However, few computer-tailored physical activity interventions in adults have provided feedback based on pedometer use.

OBJECTIVES

To (1) describe the development of a Web-based, pedometer-based, computer-tailored step advice intervention, (2) report on the dissemination of this tool through general practice, (3) report on its perceived acceptability, and (4) evaluate the preliminary efficacy of this tool in comparison with a standard intervention.

METHODS

We recruited 92 participants through general practitioners and randomly assigned them to a standard condition (receiving a pedometer-only intervention, n = 47) and a tailored condition (receiving a pedometer plus newly developed, automated, computer-tailored step advice intervention, n = 45). Step counts, self-reported data obtained via telephone interview on physical activity, time spent sitting, and body mass index were assessed at baseline and postintervention. The present sample was mostly female (54/92, 59%), highly educated (59/92, 64%), employed (65/92, 71%), and in good health (62/92, 67%).

RESULTS

Recruitment through general practitioners was poor (n = 107, initial response rate 107/1737, 6.2%); however, the majority of participants (50/69, 73%) believed it is useful that general practitioners help patients find ways to increase physical activity. In the tailored condition, 30/43 (70%) participants requested the computer-tailored step advice and the majority found it understandable (21/21, 100%), credible (17/18, 94%), relevant (15/18, 83%), not too long (13/18, 72%), instructive (13/18, 72%), and encouraging to increase steps (16/24, 67%). Daily step counts increased from baseline (mean 9237, SD 3749 steps/day) to postintervention (mean 11,876, SD 4574 steps/day) in the total sample (change of 2639, 95% confidence interval 105-5172; F(1 )= 5.0, P = .04). No interaction or other time effects were found.

CONCLUSIONS

The majority of participants in the tailored condition accepted the step advice and indicated it was useful. However, in this selected sample of adults, the tailored condition did not show superior effects compared with the standard condition.

A process evaluation of a "physical activity pathway" in the primary care setting

BACKGROUND

Let's Get Moving (LGM) is a systematic approach to integrating physical activity promotion into the primary care setting. LGM combines a number of recommended strategies to support behavior change including brief interventions, goal-setting, written resources, and follow-up support. This study involved a process evaluation of implementing LGM in UK general practice.

METHODS

The LGM intervention was implemented in six general practices in London. Practices recruited patients either 'opportunistically' in routine consultations or by letter of invitation sent to patients on the hypertension disease register. A key component of the intervention was the delivery of a brief counselling session aimed at facilitating physical activity behaviour change. Data collection methods included electronic patient records, a practice survey and focus groups and interviews with practitioners.

RESULTS

A total of 526 patients were considered for LGM, 378 via the 'opportunistic' recruitment method and 148 using the disease register approach. Patient interest in the brief counselling session was high although the actual delivery style and content varied between practitioners. Patients were directed towards a variety of physical activity opportunities including local leisure services and walking schemes.

CONCLUSION

The learning from this pilot should inform a revised update of the LGM protocols before the planned dissemination of the intervention which is outlined in the Governments 'Be Active, Be Healthy' physical activity strategy. A robust assessment of effectiveness involving an experimental design and behaviour change measures is also warranted prior to wider dissemination.

A pragmatic randomised controlled trial of the Welsh National Exercise Referral Scheme: protocol for trial and integrated economic and process evaluation

Background

The benefits to health of a physically active lifestyle are well established and there is evidence that a sedentary lifestyle plays a significant role in the onset and progression of chronic disease. Despite a recognised need for effective public health interventions encouraging sedentary people with a medical condition to become more active, there are few rigorous evaluations of their effectiveness. Following NICE guidance, the Welsh national exercise referral scheme was implemented within the context of a pragmatic randomised controlled trial.

Methods/Design

The randomised controlled trial, with nested economic and process evaluations, recruited 2,104 inactive men and women aged 16+ with coronary heart disease (CHD) risk factors and/or mild to moderate depression, anxiety or stress. Participants were recruited from 12 local health boards in Wales and referred directly by health professionals working in a range of health care settings. Consenting participants were randomised to either a 16 week tailored exercise programme run by qualified exercise professionals at community sports centres (intervention), or received an information booklet on physical activity (control). A range of validated measures assessing physical activity, mental health, psycho-social processes and health economics were administered at 6 and 12 months, with the primary 12 month outcome measure being 7 day Physical Activity Recall. The process evaluation explored factors determining the effectiveness or otherwise of the scheme, whilst the economic evaluation determined the relative cost-effectiveness of the scheme in terms of public spending.

Discussion

Evaluation of such a large scale national public health intervention presents methodological challenges in terms of trial design and implementation. This study was facilitated by early collaboration with social research and policy colleagues to develop a rigorous design which included an innovative approach to patient referral and trial recruitment, a comprehensive process evaluation examining intervention delivery and an integrated economic evaluation. This will allow a unique insight into the feasibility, effectiveness and cost effectiveness of a national exercise referral scheme for participants with CHD risk factors or mild to moderate anxiety, depression, or stress and provides a potential model for future policy evaluations.

Trial registration

Current Controlled Trials ISRCTN47680448