Factors influencing patient uptake of an exercise referral scheme: a qualitative study

Exercise referral schemes in the UK: mapping provision and aims

BACKGROUND

Exercise Referral Schemes (ERS) are designed so health professionals can refer certain patients to a supervised programme of physical activity. However, evaluations have questioned the effectiveness of these schemes/programmes. The aim of this study was to systematically review the provision of ERS in England and analyse related promotional material.

METHODS

Content analysis methods were used to analyse scheme websites and promotional material. A coding scheme was used to analyse the data, which included information on the programme's aims, inclusion criteria, type of activities, accessibility and cost.

RESULTS

The study identified 625 sites offering ERS across 168 geographic areas. Findings highlighted a lack of clarity in what constitutes a scheme. Over a third of schemes did not explicitly state their aims, but of those that did, the focus was mainly on notions of physical and mental health benefits.

CONCLUSIONS

This study is the first to review the scope and offer of ERS in the UK by examining promotional material and highlights issues around the stated aims of ERS. More clarity on aims is needed in the material that promotes the schemes and most likely within the schemes themselves. Such improvements could make a difference when considering engagement with delivery stakeholders and potential participants.

The Intersection of Health Rehabilitation Services with Quality of Life in Saudi Arabia: Current Status and Future Needs

Quality of life (QoL) is essential for maintaining a healthy, balanced lifestyle, especially among individuals with chronic diseases. Saudi Arabia (SA) launched a health sector transformation program as part of the nationwide Vision 2030 initiative to ensure the sustainable development of efficient healthcare services, aiming to improve health by increasing well-being and QoL. More investigation into the current status of health rehabilitation services provided to individuals with chronic diseases and future needs to optimize services and improve QoL is needed. This was narratively discussed by experts from different health rehabilitation services in SA. Comprehensive health rehabilitation services including orthopedic, occupational, cardiac, pulmonary, critical care, perioperative, hearing and speech, substance use disorders, and vocational rehabilitation services were addressed. Health rehabilitation services in SA, as in other countries, are suboptimal for individuals in health rehabilitation programs. To optimize the QoL of individuals with chronic diseases, health rehabilitation services should be tailored based on the unique requirements of each service and its serving patients. The shared need to improve health rehabilitation services includes the adoption of home-based and telehealth services, the integration of multi-governmental sectors, the empowerment and allocation of health rehabilitation specialists, public awareness campaigns, policy legislation and guideline development, and the implementation of a long-term follow-up system. This review is one of the first to address the intersection of health rehabilitation services and QoL in SA; urgent and holistic actions are paramount to address the pressing need to optimize SA's health rehabilitation services. The experts' recommendations in this study may be applicable to other countries' health systems, as health rehabilitation services are not well optimized globally.

Stakeholders' perceptions of barriers and facilitators for dental and mental health referrals of HIV/AIDS clinic patients

INTRODUCTION

Persons living with HIV/AIDS (PLWHA) are understudied and underserved with respect to both dental and mental health services. The coexistence of psychiatric and dental problems in PLWHA leads to more complex diagnostic assessments and treatments compared to the general population. The aim of the present study was to identify relevant themes from the perspectives of important stakeholders regarding the barriers to and facilitators of patient referral to these services.

METHOD

Semi-structured Key Informant Interviews (KIIs) were conducted with nine program directors and other key staff from New York State HIV clinics to examine barriers to and facilitators of successful dental and mental health referrals and factors that affect patient motivation.

RESULTS

Primary themes crystalized around dental and mental health referral, subject knowledge and perspective, patient barriers, and strategies to overcome barriers. Identified barriers included mental health and HIV status stigma, social determinants of health, fear, disconnectedness, and inconsistent access for dental care. Facilitators identified included case management, integrated one-stop-shop care, and interprofessional awareness and collaboration. Potential patient motivators included process improvement strategies such as transportation support, case management, incentives, and building trust.

CONCLUSION

Specific strategies to facilitate patient motivation such as care coordination and interprofessional collaboration is useful for improving dental and mental health referrals.

Optimising care coordination strategies for physical activity referral scheme patients by Australian health professionals

Physical activity (PA) has been identified as an essential tool for the prevention and management of multi-morbidity in patients. Coordination of patients’ care through interventions like physical activity referral schemes (PARS) could foster the utilization of PA. This study explored the views of General Practitioners (GPs) and Exercise Physiologists (EPs) as key stakeholders, for optimizing patient care and efficiency of PARS. Sequential explanatory mixed methods design was used to explore the perceptions of these health professionals on PA and coordination strategies for PARS patient care. Data analyses included descriptive and inferential statistics for questionnaires and theoretical framework analysis for the semi-structured interviews. Participants demonstrated a good knowledge of PA and valued PARS. However, the findings unravelled external factors, inter-organisational mechanisms, and relational coordination obstacles that hinder efficient coordination of PARS patient care and delay/limit beneficial health outcomes for patients. Incentivising the PARS initiative and empowering patients to seek referral into the programme, are strategies that could boost PARS efficiency. Improving inter-professional relationships between GPs and EPs could lead to enhanced PARS functionality and efficient coordination of care for patients with chronic diseases.

Factors associated with increased physical activity among patients prescribed physical activity in Swedish routine health care including an offer of counselor support: a 1-year follow-up

BACKGROUND

The study addresses knowledge gaps in research regarding influences of routine health care delivery of physical activity on prescription (PAP). The aim was to investigate if patient and health care characteristics are associated with increased physical activity 1 year after prescription among patients offered counselor support in addition to health care professionals' prescription. The study was conducted in primary and secondary care in a Swedish health care region.

METHODS

All PAP recipients during 1 year were invited (N = 1503) to participate in this observational prospective study. Data were collected from medical records and questionnaires (baseline and follow-up). Descriptive statistics and multiple logistic regression analysis were used. The outcome variable was increased physical activity after 1 year. Study variables were patient and health care characteristics.

RESULTS

Three hundred and fifty-five patients with complete follow-up data were included. The mean age was 62 years (SD = 14; range, 18-90) and 68% were females. Almost half (47%) had increased physical activity 1 year after PAP. Multiple logistic regression analysis showed that increased physical activity at follow-up was positively associated with lower baseline activity, counselor use, and positive perception of support. Counselor users with low baseline activity had higher odds ratio for increased physical activity at follow-up than non-users (OR = 7.2, 95% CI = 2.2-23.5 vs. OR = 3.2, 95% CI = 1.4-7.5). Positive perception of support was associated with increased physical activity among counselor users but not among non-users.

CONCLUSIONS

An increase in physical activity after PAP was related to low baseline activity, positive perception of support, and use of counselor support after PAP. Qualified counseling support linked to PAP seems to be important for achieving increased physical activity among patients with lower baseline activity.

Australian patients' perception of the efficacy of the physical activity referral scheme (PARS)

BACKGROUND

Optimum physical activity (PA) interventions could be delivered via physical activity referral schemes (PARS) if utilised adequately. However, the evidence supporting PARS effectiveness is weak due to low uptake and non-adherence to interventions.

OBJECTIVE

Patients' experiences of PARS were explored to obtain in-depth insight into their perceived quality of care and practical ways to optimise the programme's effectiveness.

METHODS

A sequential explanatory mixed methods design was employed to probe cross-sectional quantitative survey data (n = 111) on patients' knowledge and beliefs about PA and PARS and qualitative interview data (n = 15) on their experiences of PARS. Informed by Donabedian framework of healthcare quality assessment, quantitative and qualitative findings were integrated to identify practical ways to enhance PARS effectiveness.

RESULTS

Participants displayed good PA knowledge, had positive beliefs and perceived PARS to be useful. Nonetheless, bottlenecks in the structure and process of PARS impact on patient health outcomes and hinder the programme's uptake.

CONCLUSION

Exploring other referral mechanisms into PARS such as self or nurse-initiated referrals could improve the programme's visibility and effectiveness.

PRACTICE IMPLICATIONS

Improved support, enhanced visibility of EPs, ongoing interactions between GPs and EPs and education about referral pathways would foster improved uptake, adherence and health outcomes for patients.

Implementing supportive exercise interventions in the colorectal cancer care pathway: a process evaluation of the PREPARE-ABC randomised controlled trial

Background

A colorectal resection is standard treatment for patients with colorectal cancer (CRC). However, the procedure results in significant post-operative mortality and reduced quality of life. Maximising pre-operative cardiopulmonary fitness could improve post-surgical outcomes. PREPARE-ABC is a multi-centre, three-armed, randomised controlled trial investigating the effects of exercise interventions, with motivational support on short and longer-term recovery outcomes in CRC patients undergoing major lower-gastrointestinal surgery. The trial included an internal pilot phase with parallel process evaluation. The aim of the process evaluation was to optimise intervention implementation for the main trial.

Methods

Mixed methods process evaluation conducted in 14 UK hospitals between November 2016 and March 2018. Data included a site profile questionnaire and telephone scoping interview with hospital staff, 34 qualitative observations of standard care and 14 observations of intervention delivery, 13 semi-structured interviews with healthcare professionals (HCPs) and 28 semi-structured interviews with patients. Data analysis focused on describing intervention delivery within each arm, assessing fidelity, acceptability and how variation in delivery was linked to contextual characteristics.

Results

Standard care exercise advice was typically limited to maintaining current activity levels, and with lead-in time to surgery affecting whether any exercise advice was provided. Variation in HCP capacity affected the ability of colorectal units to deploy staff to deliver the intervention. Patients’ exercise history and motivation prior to surgery influenced HCP perceptions and delivery of the motivational components. Observations indicated a high level of fidelity to delivery of the exercise interventions. All but one of the 28 interviewed patients reported increasing exercise levels as a result of receiving the intervention, with most finding them motivational and greatly valuing the enhanced level of social support (versus standard care) provided by staff.

Conclusion

Hospital-supervised and home-based exercise interventions were highly acceptable for most patients undergoing surgery for CRC. Delivery of pre- and post-operative exercise within the CRC care pathway is feasible but systematic planning of capacity and resources is required to optimise implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08880-8.

Inequalities and Inclusion in Exercise Referral Schemes: A Mixed-Method Multi-Scheme Analysis

Physical activity prescription, commonly through exercise referral schemes, is an established disease prevention and management pathway. There is considerable heterogeneity in terms of uptake, adherence, and outcomes, but because within-scheme analyses dominate previous research, there is limited contextual understanding of this variance. Both the impact of schemes on health inequalities and best practices for inclusion of at-risk groups are unclear. To address this, we modelled secondary data from the multi-scheme National Referral Database, comprising 23,782 individuals across 14 referral schemes, using a multilevel Bayesian inference approach. Scheme-level local demographics identified over-sampling in uptake; on the basis of uptake and completion data, more inclusive schemes (n = 4) were identified. Scheme coordinators were interviewed, and data were analyzed using a grounded theory approach. Inequalities presented in a nuanced way. Schemes showed promise for engaging populations at greater risk of poor health (e.g., those from more deprived areas or of an ethnic minority background). However, the completion odds were lower for those with a range of complex circumstances (e.g., a mental health-related referral). We identified creative best practices for widening access (e.g., partnership building), maintaining engagement (e.g., workforce diversity), and tailoring support, but recommend changes to wider operational contexts to ensure such approaches are viable.

The Northumberland Exercise Referral Scheme as a Universal Community Weight Management Programme: A Mixed Methods Exploration of Outcomes, Expectations and Experiences across a Social Gradient

Exercise referral schemes (ERS) are internationally recognised, yet little attention has been paid to discrete referral groups or the influence of wider social determinants of health. The primary quantitative element of this mixed methods study used a mixed effects linear model to examine associations of sociodemographic predictors, obesity class and profession of referrer on weight and physical activity (PA) variables for weight-related referrals (n = 3624) to an established 24-week ERS. Chained equations modelling imputed missing data. The embedded qualitative element (n = 7) used individual semi-structured interviews to explore participant weight-related expectations and experiences. Age, gender and profession of referrer influenced weight loss. PA increased and was influenced by age and gender. The weight gap between the most and least obese narrowed over time but the PA gap between most and least widened. Age, employment and obesity class were most predictive of missing data but would unlikely alter overall conclusions. Qualitative themes were weight-loss support, personal circumstances and strategies, and weight expectations versus wellbeing rewards. This ERS worked, did not widen existing obesity inequalities, but demonstrated evidence of PA inequalities for those living with deprivation. To improve equity of experience, we recommend further stakeholder dialogue around referral experience and ongoing support needs.

Patterning in Patient Referral to and Uptake of a National Exercise Referral Scheme (NERS) in Wales From 2008 to 2017: A Data Linkage Study

Exercise referral schemes have shown small but positive impacts in randomized controlled trials (RCTs). Less is known about the long-term reach of scaled up schemes following a RCT. A RCT of the National Exercise Referral Scheme (NERS) in Wales was completed in 2010, and the scheme scaled up across Wales. In this study, using a retrospective data linkage design, anonymized NERS data were linked to routine health records for referrals between 2008 and 2017. Rates of referral and uptake were modelled across years and a multilevel logistic regression model examined predictors of uptake. In total, 83,598 patients have been referred to the scheme and 67.31% of eligible patients took up NERS. Older adults and referrals for a musculoskeletal or level four condition were more likely to take up NERS. Males, mental health referrals, non-GP referrals and those in the most deprived groupings were less likely to take up NERS. Trends revealed an overall decrease over time in referrals and uptake rates among the most deprived grouping relative to those in the least deprived group. Findings indicate a widening of inequality in referral and uptake following positive RCT findings, both in terms of patient socioeconomic status and referrals for mental health.

Attitudes towards exercise among medical specialists who manage patients with pulmonary hypertension

Exercise training was not traditionally recommended for patients with pulmonary hypertension. However, recent work has demonstrated that exercise improves endurance and quality-of-life in patients with pulmonary hypertension. Unfortunately, patients with pulmonary hypertension are often sedentary. While some studies have examined patient attitudes to exercise, none have investigated physician perspectives on exercise in patients with pulmonary hypertension. This multinational survey of physicians involved in treating patients with pulmonary hypertension sought to ascertain physician attitudes to exercise and physician-identified barriers and enablers of exercise in this patient population. We collected cross-sectional survey data from a cohort of 280 physicians, including rehabilitation physicians, cardiologists, respiratory physicians and rheumatologists. We found that overall, 86% physicians recommended exercise, in line with current guidelines, although there were differences in the rationale for prescribing exercise and in the type of exercise prescription. Barriers to exercise included patient-related factors, such as patient ill health preventing exercise; poor patient motivation and lack of understanding regarding the benefits of exercise. Systemic barriers included cost/funding issues and limited availability of appropriate services. Perceived enablers of exercise included access to appropriate programmes, provision of education and supportive treating clinicians. Further research is required to identify and implement interventions to promote physical activity in patients with pulmonary hypertension.

Are Exercise Referral Schemes Associated With an Increase in Physical Activity? Observational Findings Using Individual Patient Data Meta-Analysis From the National Referral Database

OBJECTIVES

To examine if exercise referral schemes (ERSs) are associated with meaningful changes in physical activity in a large cohort of individuals throughout England, Scotland, and Wales from The National Referral Database.

METHODS

Data were obtained from 5246 participants from 12 different ERSs, lasting 6-12 weeks. The preexercise referral scheme and changes from the preexercise to the postexercise referral scheme in self-reported International Physical Activity Questionnaire scores were examined. A 2-stage individual patient data meta-analysis was used to generate the effect estimates.

RESULTS

For the pre-ERS metabolic equivalent (MET) minutes per week, the estimate (95% confidence interval [CI]) was 676 MET minutes per week (539 to 812). For the change in MET minutes per week, the estimate (95% CI) was an increase of 540 MET minutes per week (396 to 684). Changes in the total PA levels occurred as a result of increases in vigorous activity of 17 minutes (95% CI, 9 to 24), increases in moderate activity of 29 minutes (95% CI, 22 to 36), and reductions in sitting of -61 minutes (95% CI, -78 to -43), though little change in walking (-5 min; 95% CI, -14 to 5) was found.

CONCLUSIONS

Most participants undergoing ERSs are already "moderately active." Changes in PA behavior associated with participation are through increased moderate to vigorous PA and reduced sitting. However, this was insufficient to change the International Physical Activity Questionnaire category, and the participants were still "moderately active."