Long-Term Health Outcomes Associated With an Exercise Referral Scheme: An Observational Longitudinal Follow-Up Study

A systematic review and narrative synthesis of physical activity referral schemes' components

BACKGROUND

Physical activity referral schemes (PARS) are complex multicomponent interventions that represent a promising healthcare-based concept for physical activity (PA) promotion. This systematic review and narrative synthesis aimed to identify the constitutive components of PARS and provide an overview of their effectiveness.

METHODS

Following a published protocol, we conducted a systematic search of PubMed, Scopus, Web of Science, CINAHL, ScienceDirect, SpringerLink, HTA, Wiley Online Library, SAGE Journals, Taylor & Francis, Google Scholar, OpenGrey, and CORE from 1990 to January 2023. We included experimental, quasi-experimental, and observational studies that targeted adults participating in PARS and reported PA outcomes, scheme uptake, or adherence rates. We performed an intervention components analysis using the PARS taxonomy to identify scheme components and extracted data related to uptake, adherence, and PA behavior change. We combined these to provide a narrative summary of PARS effectiveness.

RESULTS

We included 57 studies reporting on 36 PARS models from twelve countries. We identified 19 PARS components: a patient-centered approach, individualized content, behavior change theory and techniques, screening, brief advice, written materials, a written prescription, referral, baseline and exit consultation, counselling support session(s), PA sessions, education session(s), action for non-attendance, structured follow-up, a PA network, feedback for the referrer, and exit strategies/routes. The PARS models contained a mean of 7 ± 2.9 components (range = 2-13). Forty-five studies reported PA outcome data, 28 reported uptake, and 34 reported adherence rates. Of these, approximately two-thirds of studies reported a positive effect on participant PA levels, with a wide range of uptake (5.7-100.0%) and adherence rates (8.5-95.0%).

CONCLUSIONS

Physical activity referral scheme components are an important source of complexity. Despite the heterogeneous nature of scheme designs, our synthesis was able to identify 19 components. Further research is required to determine the influence of these components on PARS uptake, adherence, and PA behavior change. To facilitate this, researchers and scheme providers must report PARS designs in more detail. Process evaluations are also needed to examine implementation and increase our understanding of what components lead to which outcomes. This will facilitate future comparisons between PARS and enable the development of models to maximize impact.

Social prescribing outcomes: a mapping review of the evidence from 13 countries to identify key common outcomes

Introduction

As a means for supporting a range of health and wellbeing goals, social prescribing programs have been implemented around the world. Reflecting a range of contexts, needs, innovation, and programing, a broad array of outcomes has been studied in relation to these programs. As interest in social prescribing grows, more targeted study of key outcomes and in turn evidence synthesis that can inform evidence-based practice, policy, and investment is needed.

Methods and Results

This mapping review identified, described, and synthesized the broad array of social prescribing outcomes that have been studied in 13 countries and maps the outcomes that have been most commonly studied. From 87 articles included in this review, a total of 347 unique outcomes were identified, including 278 unique patient outcomes and 69 unique system outcomes. The most commonly studied categories of patient outcomes were found to be mental health, lifestyle and behavior, and patient/service user experience. The most commonly studied system outcomes were healthcare/service utilization and financial/economic outcomes.

Discussion

This review highlights the value of heterogeneity and mixed methods approaches in outcomes studies for capturing nuanced experiences and outcomes in this nascent area of practice, while contributing to the advancement of evidence synthesis for social prescribing globally by quantifying and offering insight into the outcomes that have been studied to date. It also lays a foundation for the development of key common outcomes and a Core Outcomes Set for social prescribing. Additionally, it identified key outcomes that, given their relationship to critical health and social issues, warrant both broader and deeper study.

Models of social prescribing to address non-medical needs in adults: a scoping review

BACKGROUND

The health and wellbeing consequences of social determinants of health and health behaviours are well established. This has led to a growing interest in social prescribing, which involves linking people to services and supports in the community and voluntary sectors to address non-medical needs. However, there is considerable variability in approaches to social prescribing with little guidance on how social prescribing could be developed to reflect local health systems and needs. The purpose of this scoping review was to describe the types of social prescribing models used to address non-medical needs to inform co-design and decision-making for social prescribing program developers.

METHODS

We searched Ovid MEDLINE(R), CINAHL, Web of Science, Scopus, National Institute for Health Research Clinical Research Network, Cochrane Central Register of Controlled Trials, WHO International Clinical Trial Registry Platform, and ProQuest - Dissertations and Theses for articles and grey literature describing social prescribing programs. Reference lists of literature reviews were also searched. The searches were conducted on 2 August 2021 and yielded 5383 results following removal of duplicates.

RESULTS

148 documents describing 159 social prescribing programs were included in the review. We describe the contexts in which the programs were delivered, the program target groups and services/supports to which participants were referred, the staff involved in the programs, program funding, and the use of digital systems.

CONCLUSIONS

There is significant variability in social prescribing approaches internationally. Social prescribing programs can be summarised as including six planning stages and six program processes. We provide guidance for decision-makers regarding what to consider when designing social prescribing programs.

Exploring how and why social prescribing evaluations work: a realist review

OBJECTIVE

The evidence base for social prescribing is inconclusive, and evaluations have been criticised for lacking rigour. This realist review sought to understand how and why social prescribing evaluations work or do not work. Findings from this review will contribute to the development of an evidence-based evaluation framework and reporting standards for social prescribing.

DESIGN

A realist review.

DATA SOURCES

ASSIA, CINAHL, Embase, Medline, PsycINFO, PubMed, Scopus Online, Social Care Online, Web of Science and grey literature.

ELIGIBILITY CRITERIA

Documents reporting on social prescribing evaluations using any methods, published between 1998 and 2020 were included. Documents not reporting findings or lacking detail on methods for data collection and outcomes were excluded.

ANALYSIS

Included documents were segregated into subcases based on methodology. Data relating to context, mechanisms and outcomes and the programme theory were extracted and context-mechanism-outcome configurations were developed. Meta-inferences were drawn from all subcases to refine the programme theory.

RESULTS

83 documents contributed to analysis. Generally, studies lacked in-depth descriptions of the methods and evaluation processes employed. A cyclical process of social prescribing evaluation was identified, involving preparation, conducting the study and interpretation. The analysis found that coproduction, alignment, research agency, sequential mixed-methods design and integration of findings all contributed to the development of an acceptable, high-quality social prescribing evaluation design. Context-mechanism-outcome configurations relating to these themes are reported.

CONCLUSIONS

To develop the social prescribing evidence base and address gaps in our knowledge about the impact of social prescribing and how it works, evaluations must be high quality and acceptable to stakeholders. Development of an evaluation framework and reporting standards drawing on the findings of this realist review will support this aim.

PROSPERO REGISTRATION NUMBER

CRD42020183065.

Depression and Exercise in Older Adults: Exercise Looks after You Program, User Profile

Introduction: Depression is a challenge for public health policies, as it is the number one leading cause of disability in the world. In order to combat and prevent it, different social and health interventions are being developed to promote health through physical activity. Objective: Analyze and describe the user profile of the patients with depression from the Exercise Looks After You program, which is a physical activity program that works on improving public health and has an essential role preventing chronic diseases and improving the quality of life of the elderly in Extremadura. Design: Cross-sectional study. Participants: total sample of 1972 users (96.4% women, 3.6% men), of whom 724 (94.6% women, 5.4% men) suffer from depression. Results: It was observed that the dominant user profile of the patients with depression within the program is female, 71 years old, physically active, overweight, married, with low educational level, non-smoker, no alcohol consumption and below average physical fitness and health-related quality of life, which translates into a high incidence of primary care, nursing and prescription visits. Conclusions: This study presents the user profile of depressive versus non-depressive participants of the Exercise Looks After You physical activity program. This data could be meaningful in order to improve and optimize public health programs and resources.

Home-Based HIIT and Traditional MICT Prescriptions Improve Cardiorespiratory Fitness to a Similar Extent Within an Exercise Referral Scheme for At-Risk Individuals

Exercise referral schemes (ERS) are used to promote physical activity within primary care. Traditionally, ERS are conducted in a gym or leisure-center setting, with exercise prescriptions based on moderate-intensity continuous training (MICT). Home-based high-intensity interval training (Home-HIIT) has the potential to reduce perceived barriers to exercise, including lack of time and access to facilities, compared to traditional MICT prescription used with ERS and improve health related outcomes. We hypothesized that Home-HIIT would mediate greater improvement in cardiorespiratory fitness (CRF) by virtue of greater adherence and compliance to the exercise prescription, compared to MICT. Methods: Patients enrolled on an ERS (Liverpool, United Kingdom) were recruited for a pragmatic trial. Participants self-selected either 12 weeks of MICT (45-135 min/week at 50-70% HR_max) or Home-HIIT (4-9 min × 1 min intervals at ≥80% of HR_max, interspersed with 1 min rest). The primary outcome was the change in CRF (VO_{2 peak}) at post-intervention (12 weeks) and follow-up (3-month post intervention), using intention-to-treat analysis. Results: 154 participants (age 48 ± 10y; BMI 30.5 ± 6.1 kg/m²) were recruited between October 2017 and March 2019, 87 (56%) participants chose Home-HIIT and 67 (44%) MICT. VO_{2 peak} increased post-intervention in both groups (MICT 3.9 ± 6.0 ml.kg^-1.min^-1, Home-HIIT 2.8 ± 4.5 ml.kg^-1.min^-1, P < 0.001), and was maintained at follow-up (P < 0.001). Fat mass was only reduced post MICT (MICT -1.5 ± 6.3 kg, P < 0.05, Home-HIIT -0.2 ± 2.0 kg, P = 1.00), but the reduction was not maintained at follow-up (MICT -0.6 ± 5.1 kg, Home-HIIT 0.0 ± 2.2 kg, P > 0.05). Adherence to the prescribed programs was similar (MICT 48 ± 35%, Home-HIIT 39 ± 36%, P = 0.77). Conclusion: This is the first study to evaluate the use of Home-HIIT for individuals in a primary care setting. Contrary to our hypothesis, adherence to both exercise prescriptions was poor, and CRF improved to a similar extent in both groups with improvements maintained at 3-month follow-up. We provide evidence that, although not superior, Home-HIIT could be an effective and popular additional exercise choice for patients within primary care based ERS. Clinical Trial Registration: [ClinicalTrials.gov], identifier [NCT04553614].

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.

Where next for the design, delivery and evaluation of community-based physical activity prescription? Emerging lessons from the United Kingdom

Despite widespread use, community-based physical activity prescription is controversial. Data limitations have resulted in a lack of clarity about what works, under what circumstances, and for whom, reflected in conservative policy recommendations. In this commentary we challenge a predominantly negative discourse, using contemporary research to highlight promising findings and 'lessons learnt' for design, delivery, and evaluation. In doing so, we argue for the importance of a more nuanced approach to future commissioning and evaluation. Contribution: • Amalgamating learning from multiple research teams to create recommendations for advancing physical activity prescription.

Evaluation of the Impact and Implementation of Social Prescribing in Primary Healthcare Units in Lisbon: A Mixed-Methods Study Protocol

BACKGROUND

Social Prescribing (SP) is an intervention to link users of the primary healthcare services to non-clinical organizations based on the community to tackle social determinants of health. Despite the potential benefits of SP, the effectiveness of this complex intervention remains uncertain. This paper presents the study protocol of the evaluation of the first SP project in Portugal.

METHODS

A mixed-methods study will be conducted to evaluate the SP project. For the quantitative component, a longitudinal, prospective study with a pre-post design will be performed. Data on patients referred to SP will be collected in four different points in time throughout the intervention, using questionnaires on patients' health status and sociodemographic characteristics, and scales on patients' well-being, quality of life and activation. The secondary data will be collected using patients' medical records and SP's forms about the referral and social responses elaborated within the intervention. Semi-structured interviews with patients and focus groups with stakeholders will be conducted to assess experiences of participation and improvement suggestions on SP.

CONCLUSION

Comprehensive and complementary evidence will provide insights and learning for the implementation of future SP interventions. This can contribute to inform policy and practice, and to increase investment in social prescribing interventions.

Understanding Leisure Centre-Based Physical Activity after Physical Activity Referral: Evidence from Scheme Participants and Completers in Northumberland UK

Physical activity referral schemes (PARS) are a popular physical activity (PA) intervention in the UK. Little is known about the type, intensity and duration of PA undertaken during and post PARS. We calculated weekly leisure centre-based moderate/vigorous PA for PARS participants (n = 448) and PARS completers (n = 746) in Northumberland, UK, between March 2019–February 2020 using administrative data. We categorised activity levels (<30 min/week, 30–149 min/week and ≥150 min/week) and used ordinal regression to examine predictors for activity category achieved. PARS participants took part in a median of 57.0 min (IQR 26.0–90.0) and PARS completers a median of 68.0 min (IQR 42.0–100.0) moderate/vigorous leisure centre-based PA per week. Being a PARS completer (OR: 2.14, 95% CI: 1.61–2.82) was a positive predictor of achieving a higher level of physical activity category compared to PARS participants. Female PARS participants were less likely (OR: 0.65, 95% CI: 0.43–0.97) to achieve ≥30 min of moderate/vigorous LCPA per week compared to male PARS participants. PARS participants achieved 38.0% and PARS completers 45.3% of the World Health Organisation recommended ≥150 min of moderate/vigorous weekly PA through leisure centre use. Strategies integrated within PARS to promote PA outside of leisure centre-based activity may help participants achieve PA guidelines.

Effectiveness of Social Prescribing Programs in the Primary Health-Care Context: A Systematic Literature Review

Social prescribing (SP) is an approach that promotes the use of local non-clinical activities by people. The referral is usually made by primary health-care professionals, in a process wherein local providers play a pivotal role. The main objective of this study was to identify domains of intervention and evidence about the effectiveness of SP programs regarding health-related outcomes. A systematic literature review was carried out following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search was conducted in PubMed, CINHAL, and SCOPUS. Inclusion criteria of the reviewed papers were as follows: (i) effectiveness studies of interventions designated as SP or interventions entailing SP conceptual components; (ii) interventions with adults. Quality assessment was performed with the Cochrane tool for assessing risk of bias in randomized trials; an assessment tool developed by the US National Heart, Lung and Blood Institute was applied to observational studies. Overall, 13 articles were included for analysis, with a total of 4603 patients. Although three studies comprised a control group, only two followed a randomized controlled trials (RCT) design. Nine principal domains of intervention within SP were identified, with three categories of outcome measures: Physical and psychological wellbeing; Health behaviors and self-efficacy; and Health care resources end economic evaluation. SP is an emergent and promising health-care intervention, and it has been used to promote different health behaviors. Evidence of SP effectiveness on patient’s health and wellbeing is not strong. Further research is needed for understanding how SP can be applied efficiently.

Pragmatic evaluation of a coproduced physical activity referral scheme: a UK quasi-experimental study

OBJECTIVES

UK exercise referral schemes (ERSs) have been criticised for focusing too much on exercise prescription and not enough on sustainable physical activity (PA) behaviour change. Previously, a theoretically grounded intervention (coproduced PA referral scheme, Co-PARS) was coproduced to support long-term PA behaviour change in individuals with health conditions. The purpose of this study was to investigate the effectiveness of Co-PARS compared with a usual care ERS and no treatment for increasing cardiorespiratory fitness.

DESIGN

A three-arm quasi-experimental trial.

SETTING

Two leisure centres providing (1) Co-PARS, (2) usual exercise referral care and one no-treatment control.

PARTICIPANTS

68 adults with lifestyle-related health conditions (eg, cardiovascular, diabetes, depression) were recruited to co-PARS, usual care or no treatment.

INTERVENTION

16-weeks of PA behaviour change support delivered at 4, 8, 12 and 18 weeks, in addition to the usual care 12-week leisure centre access.

OUTCOME MEASURES

Cardiorespiratory fitness, vascular health, PA and mental well-being were measured at baseline, 12 weeks and 6 months (PA and mental well-being only). Fitness centre engagement (co-PARS and usual care) and behaviour change consultation attendance (co-PARS) were assessed. Following an intention-to-treat approach, repeated-measures linear mixed models were used to explore intervention effects.

RESULTS

Significant improvements in cardiorespiratory fitness (p=0.002) and vascular health (p=0.002) were found in co-PARS compared with usual care and no-treatment at 12 weeks. No significant changes in PA or well-being at 12 weeks or 6 months were noted. Intervention engagement was higher in co-PARS than usual care, though this was not statistically significant.

CONCLUSION

A coproduced PA behaviour change intervention led to promising improvements in cardiorespiratory and vascular health at 12 weeks, despite no effect for PA levels at 12 weeks or 6 months.

TRIAL REGISTRATION NUMBER

NCT03490747.

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.

Health-related quality of life and physical activity level after a behavior change program at Norwegian healthy life centers: a 15-month follow-up

Purpose

The long-term impact of primary care behavior change programs on health-related quality of life (HRQoL) and physical activity (PA) level is unknown. The aim of this study was to investigate changes in HRQoL and PA among participants after a 3-month behavior change intervention at Norwegian healthy life center (HLCs) and at a 15-month follow-up. Furthermore, we aimed to study associations between changes in PA and HRQoL.

Methods

We followed 524 adult participants (18–83 years), recruited from 32 HLCs in August 2016–January 2018, who provided data on HRQoL (SF-36) and PA (ActiGraph accelerometers) 12 months after a 3-month behavior change intervention. Changes in HRQoL and PA between baseline, 3-month and 15-month follow-ups, and associations between changes in PA and HRQoL were analyzed by linear mixed models.

Results

All HRQoL dimensions improved from baseline to 3-month follow-up, and the improvements maintained at 15-month follow-up (mean 3.1–13.1 points, p < 0.001). PA increased from baseline to 3 months (mean 418 steps/day, p < 0.001), but declined from 3 to 15 months (mean − 371 steps/day, p < 0.001). We observed positive associations between changes in PA and HRQoL (0.84–3.23 points per 1000 steps/day, p < 0.023).

Conclusions

Twelve months after completing a 3-month HLC intervention we found improved HRQoL, but not PA level. Still, there were positive associations between PA and HRQoL over this period, indicating that participants increasing their PA were more likely to improve their HRQoL.