Per-protocol investigation of a best practice exercise referral scheme

Are physical activity referral scheme components associated with increased physical activity, scheme uptake, and adherence rate? A meta-analysis and meta-regression

BACKGROUND

Physical activity referral schemes (PARS) are composed of various components, such as a written prescription or a person-centered approach. The role of these components in their effectiveness is yet to be understood. Therefore, we aimed to explore the relationships between PARS components and physical activity, scheme uptake, and adherence rate; and to estimate the effect of PARS.

METHODS

We searched Scopus, PubMed, Web of Science, CINAHL, ScienceDirect, SpringerLink, HTA, Wiley Online Library, SAGE Journals, Taylor & Francis, Google Scholar, OpenGrey, and CORE. Eligible studies were published between 1990 and November 2023 in English or German, investigated PARS with participants aged ≥ 16 years, and reported physical activity, scheme uptake, or scheme adherence. Separate random-effects meta-analysis by comparison group were conducted for physical activity. Scheme uptake and adherence rates were pooled using proportional meta-analysis. The components were analyzed via univariate meta-regression. We rated the risk of bias using RoB2 and ROBINS-I, and the certainty of evidence using GRADE.

RESULTS

Fifty-two studies were included. PARS were more effective in increasing physical activity than usual care (k = 11, n = 5046, Hedges' g = 0.18, 95%CI 0.12 to 0.25; high certainty of evidence). When PARS were compared with physical activity advice or enhanced scheme versions, the pooled Hedges' g values for physical activity were -0.06 (k = 5, n = 1082, 95%CI -0.21 to 0.10; low certainty of evidence), and 0.07 (k = 9, n = 2647, 95%CI -0.03 to 0.18; low certainty of evidence) respectively. Scheme uptake was 87% (95%CI 77% to 94%, k = 14, n = 5000) across experimental studies and 68% (95%CI 51% to 83%, k = 14, n = 25,048) across non-experimental studies. Pooled scheme adherence was 68% (95%CI 55% to 80%, k = 16, n = 3939) and 53% (95%CI 42% to 63%, k = 18, n = 14,605). The meta-regression did not detect any significant relationships between components and physical activity or scheme uptake. A person-centered approach, screening, and brief advice were positively associated with scheme adherence, while physical activity sessions were negatively associated.

CONCLUSION

PARS are more effective in increasing physical activity than usual care only. We did not identify any components as significant predictors of physical activity and scheme uptake. Four components predicted scheme adherence, indicating that the component-effectiveness relationship warrants further research.

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.

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.

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

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

Facilitators and challenges in delivering a peer-support physical activity intervention for older adults: a qualitative study with multiple stakeholders

BACKGROUND

Involving peer volunteers in intervention delivery can provide social support and improve adherence. Whilst such interventions have the potential to reduce physical activity (PA) intervention costs, little is known about the process of delivering them in practice. This qualitative study explored the facilitators and challenges of delivering a peer-support PA intervention for older adults, with a view to making recommendations for the delivery of future interventions.

METHODS

Data were collected via (7) semi-structured interviews and a focus group with stakeholders involved in a peer-support PA intervention for older adults in a large city in the North-West of England. Participants included local authority staff (n = 3), peer volunteers (n = 2) and service users (n = 7). Audio data were transcribed verbatim and thematically coded to identify perceived facilitators and challenges.

RESULTS

Facilitators to delivery included social interaction, community referral pathways, suitable facilities, peer volunteers and high-quality instructors. Challenges surrounded inconsistent practice, staff capacity, safety and accountability, and awareness raising.

CONCLUSIONS

Peer volunteers can provide an additional support mechanism alongside qualified instructors for increasing social interaction within PA interventions. For optimal intervention delivery, consideration needs to be given to equipment and space, safety and accountability and consistency of practice.

[Exercise on prescription: a systematic review and socio-ecological perspectives]

OBJECTIVE

This article presents a systematic review (2009-2018) of the literature in social sciences and public health concerning exercise on prescription. The review is oriented towards studies about the beneficiaries of these prescriptions and seeks to question the use of socio-ecological indicators.

METHOD

The interrogation of bibliographic databases made it possible to retain 28 papers taking into account the following inclusion criteria: (1) publication in a peer-reviewed journal; (2) prescription of physical activity by a health professional; (3) adult beneficiaries; (4) prescription for a supervised physical activity program; (5) physical activity program of at least one month; (6) socio-demographic or psychosocial indicators complementary to age and sex only.

RESULTS

The prescription of physical activity refers to various interventions in terms of target audiences, modalities of supervision, duration of care or type of monitoring at the end of the program. The studies are mainly related to the measurement of the physical activity level during and/or after the intervention. They mobilize essentially individual indicators and analyze few other determinants from a socio-ecological perspective.

CONCLUSION

Taking into account the different types and levels of determinants, in a multidimensional approach, would make it possible to identify the social, relational and territorial factors, as well as their respective weight and their links, to refine the health promotion actions and to favor levers of access to less sedentary lifestyles and lasting changes in everyday practices.

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

BACKGROUND

Exercise referral schemes (ERSs) support inactive adults, who have chronic health conditions, to become physically active. Uncertainty exists regarding the effectiveness of ERSs, with few studies evaluating their long-term impact. The aims of this study were to evaluate the long-term impact (12 mo) of participation in an ERS on self-reported physical activity (PA) and a range of health-related outcomes.

METHODS

Data were analyzed for participants of a 24-week ERS who attended a week 52 follow-up between July 2015 and 2017. PA and health-related outcomes collected at weeks 1, 24, and 52 were analyzed using the Friedman test and Wilcoxon signed-ranks test.

RESULTS

A total of 273 participants attended the week 52 follow-up. Self-reported PA significantly increased by a median of 636 MET minutes at week 52. There were also significant improvements in body mass index, systolic blood pressure, mental well-being, and health-related quality of life.

CONCLUSIONS

For every 8 participants referred to this 24-week ERS, 1 participant went on to show long-term improvements in at least 1 health indicator. The evidence base requires further long-term evaluations to confirm these findings across a range of ERS providers. Changes in self-reported PA would be supported by the inclusion of device-based measurment of PA.

Predictors of adherence to a physical activity counseling intervention delivered by exercise physiologists: secondary analysis of the NewCOACH trial data

BACKGROUND

General practitioners (GPs) cite time as a barrier to physical activity counseling. An alternative for time-poor GPs in Australia is the referral of insufficiently active patients to exercise physiologists (EPs). As data on the predictors of adherence to physical activity counseling interventions are limited, this study aimed to identify the sociodemographic, medical, health, and psychological characteristics of insufficiently active primary care patients who adhered to a physical activity counseling intervention delivered by EPs.

METHODS

This secondary analysis of data from the NewCOACH randomized trial used logistic regression to identify predictors of adherence, defined as patient participation in at least four of the five physical activity counseling sessions. EPs provided information about the number of sessions, while other potential predictors were obtained from the self-administered baseline questionnaire and medical summary sheets provided by the GPs.

RESULTS

Of the 132 patients referred to an EP, 102 (77%) were adherent: 91 (69%) and eleven (8.3%) participated in all, or all but one, of the sessions, respectively. Of the remainder, seven (5.3%) patients participated in three sessions, seven (5.3%) participated in two sessions, five (3.8%) participated in one session, and eleven (8.3%) did not participate in any session. The odds of being adherent were 5.84 (95% CI 1.46-23.4, P≤0.05) times higher among retired participants than in those who were not in paid employment. The odds of being adherent 1) increased as the positive outcome expectation score increased (OR 1.89, 95% CI 1.12-3.18, P≤0.05) and 2) decreased as the duration (days) between referral and the initial counseling session increased (OR 0.95, 95% CI 0.92-0.98, P<0.01).

CONCLUSION

More than three quarters of the patients participated in all, or all but one, of the sessions. Being retired, positive outcome expectations, and having a shorter wait between referral and the initial appointment predicted adherence.