Functionality of Physical Activity Referral Schemes (PARS): A Systematic Review

Determinants of physical activity promotion in primary care from the patient perspective of people at risk of or living with chronic disease: a COM-B analysis

BACKGROUND

Chronic disease (CD) accounts for more than half of the overall global disease burden and physical activity (PA) is an established evidence-based strategy for the prevention and management of CD. Global policy emphasises the value of embedding PA into primary healthcare, highlighting the positive effects on PA behaviour. However, there is limited implementation of PA protocols in primary care, and research is needed to guide its integration into routine practice. The voice of the patient is underrepresented in the literature, resulting in the absence of critical insights into determinants of PA promotion in primary care. The purpose of the research was to identify the perspectives of people at risk of or living with CD on the determinants of PA promotion in primary care and to map these determinants across the six COM-B constructs.

METHODS

Semi-structured interviews (n = 22), guided by the COM-B model were conducted with people aged 35-60 years, at risk of or living with CD and not meeting the PA guidelines. A hybrid analytic approach of thematic inductive and deductive analysis was applied to the participant transcripts guided by a COM-B informed coding framework.

RESULTS

In total, 37 determinants across constructs related to capability, opportunity and motivation were prominent, examples include; physical capability constraints, the conflation of exercise with weight management, credibility of the health services in PA advice, communication styles in PA promotion, expectations of tailored support for PA, social support, accessibility, and integration of PA into routine habits.

CONCLUSION

Exploring the determinants of PA promotion through the lens of the COM-B model facilitated a systematic approach to understanding the primary care user perspective of the healthcare professional (HCP) broaching the topic of PA. Findings emphasise the value of HCPs being supported to broach the issue of PA in a therapeutic and patient-centred manner using diverse and flexible approaches, while highlighting the importance of tailored, accessible PA opportunities that build self-efficacy and foster social support. The research provides valuable learnings to support PA promotion and the development of strategies in primary care through encompassing the perspective of those living with or at risk of CD.

A co-designed mixed methods study on community-based gym exercise for non-ambulant adults with childhood onset disability

PURPOSE

Explore community-based gym exercise for non-ambulant adults with childhood-onset disability.

MATERIALS AND METHODS

Non-ambulant adults with childhood-onset disability participated in four, weekly gym sessions co-facilitated by physiotherapists and exercise professionals. Practicalities of participating in the sessions were recorded via uptake and attrition, weekly surveys, and focus groups. Perspectives of those who designed/delivered the study were gathered via weekly debrief meetings. Quantitative data were analysed descriptively, qualitative data were analysed thematically.

RESULTS

Ten non-ambulant adults with childhood-onset disability participated; 70% completed all exercise sessions. Focus groups identified three themes. "I wouldn't be able to exercise…there's no option for a community-based setting" described the lack of opportunities for exercise in gyms. "You don't realise the benefit of coming here" highlighted benefits of exercise. "We can do better" had two sub-themes: problem solving and ingredients for community-based gym exercise. Weekly feedback and debrief meetings identified practicalities related to equipment, exercises, and collaborative working between facilitators.

CONCLUSIONS

Whilst there is an interest in community-based gym exercise for non-ambulant adults with childhood-onset disability, there remains a lack of inclusive gyms. Co-design of inclusive gym guidelines and condition-specific physical activity referral scheme may enhance opportunities for participation in gym exercise for adults with childhood-onset disability.

Common barriers and enablers to the use of non-drug interventions for managing common chronic conditions in primary care: an overview of reviews

BACKGROUND

Non-drug interventions are recommended for chronic condition prevention and management yet are underused in clinical practice. Understanding barriers and enablers to using non-drug interventions may help implement non-drug interventions in primary care. We aimed to conduct an overview of reviews to identify and summarise common barriers and enablers for using non-drug interventions for common chronic conditions in primary care.

METHODS

We included qualitative and quantitative reviews that used systematic process or methods to examine barriers and enablers to using non-drug interventions for chronic condition prevention and management in primary care settings. We searched 5 electronic databases (PubMed, Cochrane Database of Systematic Reviews, EMBASE, PsycInfo and CINAHL) from inception to September 2022. Two authors independently screened reviews. One author extracted and deductively coded data to Consolidated Framework of Implementation Research (CFIR) (and where relevant, Theoretical Domains Framework [TDF]). A second author validated 10% of extracted data and coding. Data was synthesised thematically using CFIR and TDF. One author assessed the methodological quality of included reviews using a modified AMSTAR 2 tool, with 10% validated by a second author. We assessed overlap between primary studies in included reviews.

RESULTS

From 5324 records, we included 25 reviews, with data predominately from patients. Overall, 130 subthemes (71 barrier and 59 enabler) were identified across 4 CFIR domains (Innovation, Outer Setting, Inner Setting, and Individuals), and all TDF domains. Common barrier and enabler subthemes were identified for CFIR constructs of Innovation Adaptability, Innovation Cost, Innovation Relative Advantage, Local Attitudes, External Pressure, Local Conditions, Relational Connections, Available Resources, and Access to Knowledge and Information. For TDF domains, important barrier and enabler subthemes were identified for Knowledge, Skills, Environmental Context and Resources, Beliefs about Consequences, Reinforcement, and Emotion.

CONCLUSIONS

We synthesised reviews to provide new insight into common barriers and enablers for using non-drug interventions to prevent and manage chronic conditions in primary care. The factors identified can inform the development of generalisable implementation interventions to enhance uptake of multiple non-drug interventions simultaneously.

TRIAL REGISTRATION

This study was registered in PROSPERO (CRD42022357583).

Physical Activity with Sports Scientist (PASS) programme to promote physical activity among patients with non-communicable diseases: a pragmatic randomised controlled trial protocol

Physical activity (PA) effectively prevents and treats non-communicable diseases in clinical settings. PA promotion needs to be more consistent, especially in busy primary care. Sports scientists have the potential to support PA promotion in primary care. The Physical Activity with Sports Scientist (PASS) programme is created to personalise PA promotion led by a sports scientist in a primary care clinic. A pragmatic randomised controlled trial with two parallel groups will be conducted at a family medicine clinic. Physically inactive participants aged 35-70 years who have type 2 diabetes mellitus, hypertension or dyslipidaemia will be invited. The control group (n=60) will receive usual care. The intervention group (n=60) will receive the PASS programme and usual care. The PASS programme will consist of a tailored PA prescription after the physician's consultation at the first visit and monthly phone follow-ups. The primary outcome is the proportion of participants who have achieved the PA goal defined as aerobic activity (≥150 min/week of moderate to vigorous-intensity PA), muscle-strengthening activity (≥2 days/week of moderate or greater intensity) and multicomponent PA (≥2 days/week of moderate or greater intensity). Secondary outcomes are body composition and physical fitness. The primary and secondary outcomes will be measured and compared between the control and intervention groups at visit 1 (month 0: baseline measurements), visit 2 (months 3-4: follow-up measurements), visit 3 (months 6-8: end-point measurements) and visit 4 (months 9-12: continuing measurements). The study protocol was registered with the Thai Clinical Trials Registry. Trial registration number: TCTR20240314001.

Physical activity on prescription for children with obesity: a focus group study exploring experiences in paediatric healthcare

Background

Insufficient physical activity is a growing public health concern and is closely linked to obesity in both adults and children. Swedish physical activity on prescription (PAP) is effective in increasing physical activity levels in adults, but knowledge about how PAP is used in paediatric healthcare is lacking. Therefore, this study aimed to explore experiences of working with PAP for children with obesity amongst paediatric staff and managers.

Methods

Seven focus group discussions with 26 participants from paediatric outpatient clinics in western Sweden were conducted. Data were analysed both inductively and deductively, framed by the Normalization Process Theory's four core constructs: coherence, cognitive participation, collective action, and reflexive monitoring.

Results

The PAP work for children with obesity was experienced to be about helping children to become physically active, and less about losing weight. Identified barriers for using PAP were the non-uniform nature of the work and a perceived lack of guidelines. Collaboration with physiotherapists and physical activity organisers outside the organisation was identified as an important facilitator. An important contextual factor for implementing PAP is the collaboration between paediatric clinics and physical activity organisers. In the transition between these stakeholders, maintaining a family-centred approach when working with PAP was experienced as challenging.

Conclusions

PAP is a well-known intervention that is inconsistently used for children with obesity. The intervention should include a family-centred approach for this patient group. It also needs to align better with existing collaborations with other healthcare units as well as with new forms of collaboration with physical activity organisers in the community.

Capitalization of experience of physical activity resumption programs: Lessons learned for adherence and post-program referral

The benefits of physical activity (PA) in managing chronic diseases are largely demonstrated. To encourage a sustainable PA practice for inactive patients with chronic diseases, France has recently implemented PA resumption programs, in which patients can participate with a medical prescription but which are time-limited. In the literature, the effectiveness of those exercise referral schemes to foster sustainable PA practice is still mixed. The present study aims at capitalizing the experience of eight resumption programs to understand what makes the programs work, adherence mechanisms and the post-program referral scheme. Questionnaires and semi-structured interviews informed those intervention mechanisms analysed using thematic analysis. This study provides insights into expertize in patient management among these programs, currently due to key findings as the employment of adapted PA teachers, their training and the use of mechanisms for program adherence (practice conditions, emphasize progress and feelings generated by exercise, the relational and social aspect of practice). Other key findings are a lack of clarity in program objectives which is an area of improvement, and a broad diversity of referral (transmitting contact details, contacting the club, intervention of a third-party association or physical presence) that need further exploration.

Exploring the Health Effectiveness of a Physical Activity Program Co-Constructed with Students after the COVID-19 Pandemic

BACKGROUND

University students have low levels of physical activity and high levels of sedentary behaviors that were exacerbated by the COVID-19 pandemic. Even before the pandemic, there was poor uptake of university sports activities. Therefore, it is essential to develop and test innovative programs to increase students' motivation to engage in physical activity in order to prevent any future deterioration in their general health.

OBJECTIVE

This exploratory study was conducted to test the effectiveness of a physical activity program that was co-constructed with students.

METHODS

First, a workshop drawing on social design methodologies and the fundamentals of physical activity programs was conducted to assess students' needs and desires in terms of physical activity. Second, the effectiveness of a program co-constructed with students on the basis of this workshop was assessed on physical and mental health parameters. The results showed that the workshop outcomes allowed the physical activity program to be tailored to meet students' expectations (e.g., session duration and type of activities). This innovative physical activity program was found to improve body image, autonomous motivation, and certain physical parameters. At the end of the 8-week program, the adherence rate was 89%, and 83% of the final respondents expressed a wish to re-enroll for the following semester.

CONCLUSIONS

Involving students and considering their wishes, needs, and objectives could facilitate the development of attractive and innovative programs.

Summary and application of the WHO 2020 physical activity guidelines for patients with essential hypertension in primary care

The new World Health Organization (WHO) 2020 guidelines on physical activity (PA) and sedentary behavior include recommendations for adults with chronic conditions. The guidelines provide adaptable and general recommendations for people living with chronic medical conditions. This article summarizes the content and provides suggestions for the application of the guidelines for patients with essential hypertension in primary care. The WHO 2020 PA guidelines recommend broad advice for adults and older adults with chronic conditions. The key recommendations are consistent with other hypertension guidelines. A systemic approach to promote PA in primary care (i.e., PA assessment, safety considerations, PA prescription, behavioral counseling, and referral) along with applying the WHO guidelines is required. Health risk assessment and safety issues related to hypertension (e.g., current PA levels, level of blood pressure, treatment plans, comorbidities) should be concerned. The FITT Pro (frequency, intensity, time, type, and progression) can be adopted as a framework to break down the guidelines into specific PA prescription. The WHO 2020 PA guidelines address the importance of PA in clinical populations. The guidelines can be adapted for patients with hypertension in primary care settings.

PERSISTE: a mixed methods protocol to identify barriers and levers to a sustainable physical activity practice among patients with chronic disease after physical activity resumption programs

Physical activity (PA) has evidence-based benefits for physical, social and mental health, but investigation of how PA interventions for patients with chronic disease affects their PA practice up to 1 year after programmes are rare. Moreover, few studies document how the context and intervention mechanisms of PA programmes affect sustainable PA practice and its determinants. The present protocol describes a mixed methods study comparing the effectiveness and conditions for the effectiveness of two PA resumption programmes (a hospital-led and a community-based programme). Using a comparative longitudinal study, 60 patients (3-month duration) will be followed for 1 year though four data collections: before (T0) and at the end (T1) of the intervention, 6 months (T2) and 1 year (T3) after the start of the programme. The primary outcome will be PA practice in min/week and categorised as light, moderate or vigorous (using International Physical Activity Questionnaire (IPAQ)), and secondary outcomes will include sedentary time in min/week (IPAQ), quality of life evaluated though the physical and mental composite scores ('Medical Outcome Study Short Form 12'), and enjoyment using four statements rated from 1 to 5, a high score being synonymous of enjoyment (Intrinsic Motivation Inventory). Qualitative data on further determinants of PA practice and intervention mechanisms will be collected. The expected results will offer the opportunity to understand how the intervention context contributes to a more effective, sustainable PA practice. Trial registration number: NCT04954209.

Prerequisites for implementing physical activity on prescription for children with obesity in paediatric health care: A cross-sectional survey

Background

Physical inactivity is a main driver of childhood obesity that tracks into adulthood, making it crucial to address early in life. Swedish physical activity on prescription (PAP) is an effective intervention for increasing physical activity levels in adults and is being implemented in primary care in Sweden. Before implementing PAP for children, both intervention effectiveness and implementation prerequisites need to be examined. Framed by the Normalization Process Theory (NPT) domains, this study aimed to investigate perceptions of PAP amongst paediatric staff and managers working with children with obesity, as well as acceptability, appropriateness, feasibility, and barriers and facilitators for implementing PAP in paediatric health care.

Methods

Staff and managers in 28 paediatric outpatient clinics in western Sweden were surveyed using validated implementation instruments and open-ended questions. Data were analysed using Mann-Whitney U tests and Kruskal-Wallis tests. Qualitative data were categorised into NPT domains.

Results

The survey response rate was 54% (125/229). Most respondents (82%) reported PAP to be familiar and many (56%) perceived it as a normal part of work; nurses and physiotherapists to a greater extent (p < 0.001). This was anticipated to increase in the future (82%), especially amongst those with the longest work experience (p = 0.012). Respondents reported seeing the potential value in their work with PAP (77%), being open to working in new ways to use PAP (94%), and having confidence in their colleagues' ability to use PAP (77%). Barriers and facilitators were found in all the NPT domains, mainly collective action and reflexive monitoring, where, for example, inadequacies of education, resources, and research on PAP for children were reported as barriers. Most respondents agreed that PAP was acceptable, appropriate, and feasible (71% to 88%).

Conclusions

PAP is familiar and perceived as an acceptable, appropriate, and feasible intervention, and by many viewed as a normal part of clinical routines in paediatric outpatient clinics in western Sweden, especially by physiotherapists and nurses. Barriers and faciliators are mainly related to collective action and reflexive monitoring. The wide acceptance demonstrates receptiveness to PAP as an intervention to promote an active lifestyle for children with obesity.

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.

How safe is prehospital care? A systematic review

Background

As compared to other domains of healthcare, little is known about patient safety incidents (PSIs) in prehospital care. The aims of our systematic review were to identify how the prevalence and level of harm associated with PSIs in prehospital care are assessed; the frequency of PSIs in prehospital care; and the harm associated with PSIs in prehospital care.

Method

Searches were conducted of Medline, Web of Science, PsycInfo, CINAHL, Academic Search Complete and the grey literature. Reference lists of included studies and existing related reviews were also screened. English-language, peer-reviewed studies reporting data on number/frequency of PSIs and/or harm associated with PSIs were included. Two researchers independently extracted data from the studies and carried out a critical appraisal using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD).

Results

Of the 22 included papers, 16 (73%) used data from record reviews, and 6 (27%) from incident reports. The frequency of PSIs in prehospital care was found to be a median of 5.9 per 100 records/transports/patients. A higher prevalence of PSIs was identified within studies that used record review data (9.9 per 100 records/transports/patients) as compared to incident reports (0.3 per records/transports/patients). Across the studies that reported harm, a median of 15.6% of PSIs were found to result in harm. Studies that utilized record review data reported that a median of 6.5% of the PSIs resulted in harm. For data from incident reporting systems, a median of 54.6% of incidents were associated with harm. The mean QATSDD score was 25.6 (SD = 4.1, range = 16–34).

Conclusions

This systematic review gives direction as to how to advance methods for identifying PSIs in prehospital care and assessing the extent to which patients are harmed.

The 'PRICE' of Physical Activity Referral Schemes (PARS): Stakeholders' Recommendations for Delivering Quality Care to Patients

Evidence-based strategies are needed to curb the growing cases of physical inactivity related morbidities. Delivering holistic care through collaborative shared decision making could boost the effectiveness of physical activity referral schemes (PARS) and foster the quality of care for patients with multimorbidity. A qualitative study involving semi-structured telephone interviews was utilised to gain insights from Australian PARS stakeholders (general practitioners, exercise physiologists, and patients). A pluralistic evaluation approach was employed to explore and integrate participants' opinions and experiences of PARS and their recommendations were used to develop a model for quality care delivery in PARS initiatives. Five overarching themes: promote, relate, incentivise, communicate, and educate were identified as the 'PRICE' for developing effective and functional PARS programmes that foster quality patient care. It was evident that PARS programmes or policies aimed at optimising publicity, encouraging incentives, improving interdisciplinary information sharing and professional relationships between patients and healthcare professionals can transform healthcare delivery and provide top quality PARS care services to patients. Therefore, governments, healthcare systems, and PARS administrators can translate and leverage the insights from this study to optimise the delivery of high quality care to PARS patients.

Physical activity referral scheme components: a study protocol for systematic review and meta-regression

INTRODUCTION

In its attempt to establish effective physical activity promotion methods, research on physical activity referral schemes (PARS) is attracting significant attention. Sometimes known as physical activity on prescription schemes, PARS involve a well-defined procedure whereby a primary healthcare professional introduces a participant to the topic of physical activity and employs prescription or referral forms to connect the participant to physical activity opportunities, such as local fitness offers. The planned systematic review will focus on these referral routes and scheme components and how they are integrated into various PARS models worldwide. We seek to identify the evidence-based core components that play the most important roles in the effectiveness of PARS.

METHODS AND ANALYSIS

The development and reporting of the protocol follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We plan to conduct a systematic main literature search on PubMed, Scopus, Web of Science, CINAHL, HTA, SpringerLink and other databases. We will include studies that report outcomes on physical activity, PARS uptake and adherence rates or descriptive information about PARS models. We intend for all review stages, citation screening, data extraction and risk of bias assessment to be conducted by at least two independent reviewers. As a broad spectrum of study designs, including randomised and non-randomised studies of interventions and mixed methods, will be eligible, we will use three separate tools to assess the risk of bias in individual studies. The data will be primarily synthesised narratively, following Intervention Component Analysis. If the data allow, we will perform a random-effects meta-analysis and meta-regression to investigate the impact of specific PARS components on effect sizes.

ETHICS AND DISSEMINATION

This systematic review does not require formal ethics approval. The results will be submitted to a peer-reviewed journal and international conferences to reach the scientific community.

PROSPERO REGISTRATION NUMBER

CRD42021233229.