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

A stepped down physical activity support program for military service veterans: The Active Choices pilot study

ISSUE ADDRESSED

Referral to supervised physical activity (PA) programs is an effective treatment for military service veterans (MSVs) suffering from a range of chronic diseases. However, many MSVs fail to maintain PA regimes once discharged from supervision. This pilot study assessed Active Choices, a stepped-down program to support MSVs in the transition from allied health treatment to self-managed PA.

METHODS

Participants were 34 Australian MSVs (mean [SD] age = 61 [15.8] years) who were completing supervised referral to an exercise physiologist or physiotherapist. MSVs stepped-down to Active Choices and received a 12-week, evidence-based PA support program (2020-2021). Analyses compared within-group changes in accelerometer-assessed PA at three time points (Weeks 0, 12, and 24; linear mixed model). Program retention, PA choices, and allied healthcare service costs were also evaluated.

RESULTS

Relative to baseline (64 [26] min/day), mean (SD) moderate-to-vigorous PA increased (74 [28] min/day; p < .05) and was maintained (62 [28] min/day) at weeks 12 and 24, respectively. Retention in the program was high (86% [29/34 participants] completion rate at 12 weeks), with water-based group activities the most popular PAs of choice (14/24 activities). Average allied healthcare service costs during the study were lower than typical costs for MSVs (60.51 vs. 97.06 AUD/week).

CONCLUSION

The findings highlight the potential of Active Choices to support MSVs in the transition from supervised to self-managed MVPA. SO WHAT?: The program could promote the health of veterans and reduce costs for ongoing referral if impact is replicated at scale.

Dual pathway inhibition as compared to acetylsalicylic acid monotherapy in relation to endothelial function in peripheral artery disease, a phase IV clinical trial

Objective

Dual pathway inhibition (DPI) by combining acetylsalicylic acid (ASA) with low-dose rivaroxaban has been shown to reduce cardiovascular events in patients with peripheral arterial disease (PAD) when compared to ASA monotherapy. A potential explanation is that inhibition of factor Xa improves endothelial function through crosstalk between coagulation and inflammatory pathways, subsequently attenuating the occurrence of cardiovascular events. We hypothesize that the addition of rivaroxaban to ASA in PAD patients leads to improved endothelial function.

Design

An investigator-initiated, multicentre trial investigating the effect of DPI on endothelial function.

Methods

Patients, diagnosed with PAD, were enrolled in two cohorts: cohort A (Rutherford I-III) and cohort B (Rutherford IV-VI). Participants received ASA monotherapy for a 4-weeks run-in period, followed by 12 weeks of DPI. Macro- and microvascular endothelial dysfunction were studied by measuring carotid artery reactivity upon sympathetic stimulus and by measuring plasma endothelin-1 concentrations, respectively. All measurements were performed during the use of ASA (baseline) and after 12 weeks of DPI.

Results

159 PAD patients (111 cohort A, 48 cohort B) were enrolled. Twenty patients discontinued study drugs early. Carotid artery constriction upon sympathetic stimulation at baseline (ASA) and after 12 weeks of DPI was similar in the total group, 22.0 vs. 22.7% (p = 1.000), and in the subgroups (Cohort A 22.6 vs. 23.7%, p = 1.000; cohort B 20.5 vs. 20.5%, p = 1.000), respectively. The mean concentration of plasma endothelin-1 at baseline and after 12 weeks of DPI did not differ, 1.70 ± 0.5 vs. 1.66 ± 0.64 pmol/L (p = 0.440) in the total group, 1.69 ± 0.59 vs. 1.62 ± 0.55 pmol/L in cohort A (p = 0.202), and 1.73 ± 0.53 vs. 1.77 ± 0.82 pmol/L in cohort B (p = 0.682), respectively.

Conclusion

Macro- and microvascular endothelial dysfunction, as reflected by carotid artery reactivity and plasma endothelin-1 concentrations, are not influenced in PAD patients by addition of low-dose rivaroxaban to ASA monotherapy for 12 weeks.

Trial registration

https://clinicaltrials.gov/ct2/show/NCT04218656.

Co-creating physical activity interventions: Findings from a multiple case study using mixed methods

Introduction

In health and physical activity promotion, there is growing interest in co-creation approaches that involve researchers and non-academic stakeholders in developing new interventions. Previous research has shown the promising results of cooperative planning as a co-creation approach in building new capacities and implementing physical activity-promoting interventions in nursing care and automotive mechatronics. However, it remains unclear whether (1) cooperative planning for physical activity promotion can be successfully transferred to other settings in the nursing care and automotive mechatronic sectors and (2) what key factors influence its success or failure.

Methods

We conducted a multiple case study in three settings in the nursing care and automotive mechatronics sectors. Following a mixed methods approach, we collected, analyzed, and triangulated data from documents (n = 17), questionnaires (n = 66), and interviews (n = 6). Quantitative data were analyzed descriptively and through using nonparametric analyses of variance; qualitative data were analyzed using qualitative content analysis by extraction.

Results

The transfer of cooperative planning to new settings was realized, though the impact varied by setting. While the interventions were developed and implemented in nursing care settings, interventions were developed but not implemented in the automotive mechatronics setting. In this context, intervention implementation was influenced by 11 key factors: champion, commitment, embedment, empowerment, engagement, health-promoting leadership, ownership, relevance, resources, responsibility, and strategic planning. Furthermore, the transfer of cooperative planning was influenced by different activity characteristics, namely elaboration & reconsideration, group composition, number of meetings, participation, period, prioritization, and researchers' input & support.

Discussion

The present article contributes to a better understanding of a co-creation approach utilized for physical activity promotion and provides new insights into (1) the transferability of cooperative planning and (2) the associated key factors influencing intervention implementation. The success of cooperative planning varied by setting and was influenced by several activity characteristics and key factors, some of which showed complex relationships. This raises the question of whether some settings might benefit more from a co-creation approach than others. Therefore, future co-creation initiatives should carefully consider the specific characteristics of a setting to select and apply the most appropriate approach.

The GRANDPACT Project: The Development and Evaluation of an Intergenerational Program for Grandchildren and Their Grandparents to Stimulate Physical Activity and Cognitive Function Using Co-Creation

In recent years, increased attention has been devoted to intergenerational physical activity (PA) programs because they may have several benefits for both children and older adults (e.g., the reduction of ageism). An intergenerational PA program focusing on grandchildren and grandparents in a 'standard' family setting that combines PA and cognitive function is innovative and may hold potential for promoting PA and improving cognitive functioning in both grandchildren and grandparents. The aim of this study is to describe the protocol of the GRANDPACT (GRANDparents and GRANDchildren improve their Physical Activity and Cognitive functions using co-creaTion) Project, focusing on the development of an intergenerational, cognitively enriched, movement program for grandchildren and grandparents using the theoretical framework of the "Behaviour Change Wheel" in combination with a co-creation approach. Two co-creation trajectories will be organized to develop the program, followed by a pilot study to refine the program and an RCT with a pre-test (at baseline), a post-test (after 24 weeks), and a follow-up (after 36 weeks) to measure the outcomes of co-PA, cognitive functions, psychosocial well-being, and the quality of the family relationship ingrandchildren and grandparents. The outcomes will be measured using accelerometry for PA, the Cambridge Neuropsychological Test Automated Battery (CANTAB) for cognitive functions, and questionnaires for the psychological well-being and quality of the family relationship. Co-development with end-users and stakeholders during both co-creation trajectories is expected to result in an effective, attractive, and feasible program. Co-PA is expected to improve PA, cognitive functioning, psychosocial well-being, and the quality of the family relationships between grandchildren and grandparents.

Levels of Adherence of an Exercise Referral Scheme in Primary Health Care: Effects on Clinical and Anthropometric Variables and Depressive Symptoms of Hypertensive Patients

Among the modifiable health behaviors, physical activity (PA) promotion has been one of the challenges in primary care, particularly how to translate the results of proven interventions and implement them in the real world. This study was aimed to compare whether two programs designed for hypertensive patients achieve changes in clinical and anthropometric variables, quality of life, and depressive symptoms; and if higher levels of adherence to one of the interventions using an exercise referral (ER) approach achieved better health outcomes. Pragmatic cluster randomized trials were carried out in four Primary Health Care Units (PHCUs). Physicians in the PHCUs identified hypertensive patients and assessed whether they were eligible to be part of this trial. Each center was randomized to a brief PA counseling (BC, n = 2) or an exercise referral (ER, n = 2) intervention to conducted PA programs among hypertensive patients aged 35–70 years, self-reported as physically inactive. Outcome variables included changes in blood pressure levels, triglycerides, HDL cholesterol, fasting glucose, body mass index, waist/hip ratio, abdominal obesity, and metabolic syndrome risk score, health-related quality of life, and depressive symptoms. Longitudinal multilevel analyses assessed the effects of the BC and ER programs and the level of adherence of the ER on clinical, anthropometric, and mental health variables, models were linear for continuous variables, and logistic for dichotomous variables. Differences were observed in triglycerides, BMI, metabolic risk scores variables, and depressive symptoms among ER and BC programs. In addition, differences in the ER group were observed according to the level of adherence in blood pressure levels, waist circumference and waist/hip ratio, depressive symptoms, and the mental health component of health-related quality of life. An ER program in comparison to a BC intervention is promoting changes in some specific health indicators of hypertensive patients, showing the usefulness of these PA programs in primary health care facilities.

Introducing the Practice Dive Approach: an extension of co-creation in physical activity promotion and health promotion

Recently, there has been increasing interest in co-creation utilized for physical activity (PA) promotion and health promotion. Co-creation involves researchers and non-academic stakeholders conjointly developing and implementing interventions. In addition to the frequently reported benefits of co-creation, critical voices highlight the associated challenges (e.g. different interests that inhibit interaction). So far, research has not identified concrete solutions to these challenges and the limitations of co-creation. This article aims to introduce the Practice Dive Approach as a potential way to strengthen cooperation between researchers and non-academic stakeholders. We build on real-life experiences from a German research project, in which researchers moved into practice to familiarize themselves with the settings and end-users. After conducting a literature search on related concepts in PA/health promotion, we developed a comprehensive approach to fostering multi-sectoral cooperation. The introduced Practice Dive Approach assumes that a significant contribution to better cooperation among co-creators is the temporal immersion of researchers in their setting of interest, which has the potential to improve the success of co-creation in the PA/health promotion field. A four-level typology characterizes the intensity of researcher interactions with the setting and the non-academic stakeholders. Potential beneficial effects for both researchers and non-academic stakeholders can be hypothesized (e.g. familiarity with the setting structures and increased understanding of the end-users), while simultaneously, some challenges need to be considered. Future research should aim to validate the concept and its postulated effects.

Collaboration among researchers and non-academic stakeholders is increasingly used to promote physical activity and health. For example, people involved in such collaborations jointly develop new interventions. Potential challenges include different interests or work routines that can complicate cooperation. This article aims to introduce the Practice Dive Approach as a potential way to improve cooperation between researchers and non-academic stakeholders. We developed the approach based on observations from a German research project and a literature search on related concepts. This approach assumes that the temporal involvement of researchers in their setting of interest can strengthen research-practice cooperation and improve its success. We describe different types of a Practice Dive and the requirements for conducting Practice Dive activities. Furthermore, we present the potential effects of a Practice Dive for the researchers and the non-academic stakeholders, such as increased familiarity between both groups. However, some challenges need to be considered when applying the Practice Dive Approach. Future research should test this approach and its potential effects.

Coproduction to improve preventive health services-experiences from Germany

Due to the beneficial impact of regular physical activity (PA) on non-communicable diseases, the number of countries integrating exercise referral schemes (ERSs) into their healthcare systems is growing. Owing to the limitations of existing PA promotion concepts in Germany’s healthcare system, efforts are currently being made towards developing a nationwide referral pathway. A research group at the Friedrich-Alexander-University Erlangen-Nürnberg is coordinating these efforts within a project funded by the Federal Ministry of Health. The aim is to develop, implement and evaluate a regional-level ERS that has the potential to be scaled up across Germany in the event of its demonstrated effectiveness. The project is based on an adapted Cooperative Planning approach requiring interaction between the academic sector and different actors of the healthcare sector. The present commentary reflects on challenges faced in the early stages of the co-production process. Besides the development of an adequate co-production methodology, it critically discusses stakeholder participation, knowledge gaps and actors’ willingness to take responsibility. In addition, although patients are represented by dedicated organizations, their perspective cannot be adequately captured using a co-production approach. Despite the joint development of an ERS, there remain important questions regarding the appropriateness of the co-production approach in a healthcare setting.

Regular physical activity (PA) reduces one’s risk of developing various diseases and also plays a favourable role in managing symptoms and preventing further complications. Nationally and internationally, there exist different concepts on how to increase PA in the population at large. The Friedrich-Alexander-University Erlangen-Nürnberg is currently working on a project that focuses on promoting PA in primary care. This project involves collaboration among various actors in the German healthcare system, such as healthcare insurances, representatives of physicians, patients and exercise specialists, who represent different interests and are experts in their fields of knowledge. During this process, various barriers have come to light, which yield important lessons for further studies. For example, there are differences in actors’ levels of knowledge of the healthcare system and their willingness to take responsibility and initiative in the collaborative process. This article should give an impression of the joint development of exercise referral schemes, show the strengths and weaknesses and encourage exchanges of similar experiences of co-production processes.

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.

Co-Production Performance Evaluation in Healthcare. A Systematic Review of Methods, Tools and Metrics

Co-produced practices and publications in the healthcare sector are gaining momentum, since they can be a useful tool in addressing the sustainability and resilience challenges of health systems. However, the investigation of positive and, mainly, negative outcomes is still confused and fragmented, and above all, a comprehensive knowledge of the metrics used to assess these outcomes is lacking. To fill this gap, this study aims to systematically review the extant literature to map the methods, tools and metrics used to empirically evaluate co-production in health services. The search took place in six databases: Scopus, Web of Science, Psych INFO, PubMed, Cochrane and CINAHL. A total of 2311 articles were screened and 203 articles were included in the analysis, according to PRISMA guidelines. Findings show that outcomes are mainly investigated through qualitative methods and from the lay actor or provider perspective. Moreover, the detailed categorisation of the quantitative measures found offers a multidimensional performance measurement system and highlights the impact areas where research is needed to develop and test new measures. Findings should also promote improvements in empirical data collection on the multiple faceted co-produced activities and spur the consciousness of the adoption of sustainable co-productive initiatives.

Development, implementation, evaluation and scaling-up of physical activity referral schemes in Germany: protocol for a study using a co-production approach

INTRODUCTION

Physical activity referral schemes (PARSs) are recommended to promote physical activity (PA) among adults at risk of developing or with established non-communicable diseases (NCDs). In Germany, this kind of referral schemes has not yet been implemented systematically and nationwide. In this study protocol, we present the methodological design of a co-production research study aimed at establishing a PARS for adults with NCDs in German primary healthcare.

METHODS AND ANALYSIS

We will employ a co-production approach consistently throughout the four project phases: (1) development of the PARS; (2) preparation period; (3) implementation and evaluation; (4) development of a strategic plan for scaling up the PARS to the national level as part of standard care. The first phase will additionally include a status quo analysis of the existing physical activity pathways nationwide as well as an overview of international PARS models. A pragmatic trial design will be used for evaluating the developed PARS. The co-production approach will involve relevant actors in the German healthcare system, namely, healthcare service providers (eg, physicians, exercise professionals), health insurance providers, exercise providers, patients' representatives, experts in the development and implementation of educational concepts, and scientists from the fields of sports science and public health.

ETHICS AND DISSEMINATION

The project has been reviewed and approved by the ethics committee of the Friedrich-Alexander-University Erlangen-Nürnberg (ethics approval number: 331_20 B). Through cooperation agreements, the stakeholders involved gave their consent to participate and were informed about the study in detail. The results of this study will be disseminated by international conference presentations and peer-reviewed publications, and if possible, a manual for the use of the PARS will be provided.