The connection between the primary care and the physical activity sector: professionals' perceptions

A movement for movement: an exploratory study of primary healthcare professionals' perspectives on implementing the Royal College of General Practitioners' active practice charter initiative

BACKGROUND

Regular physical activity (PA) results in extensive physical, psychological, and social benefits. Despite primary care being a key point of influence for PA behaviours in the UK, research indicates poor application of PA interventions in this context. To address this, the Royal College of General Practitioners' (RCGP) developed and implemented the Active Practice Charter (APC). The aim of the study was to evaluate the perceived impact and acceptability of the APC initiative from the perspective of primary healthcare professionals (PHPs).

METHODS

An online exploratory cross-sectional survey was designed to assess the perceived impact, experiences, and challenges of the APC initiative, from the perspective of PHPs. The survey was distributed by the RCGP via email to 184 registered APC practices across the UK.

RESULTS

Responses were reviewed from staff (n = 33) from 21 APC practices. Initiatives used by APC practices included: educational programmes, partnerships with PA providers, referral systems, and infrastructure investment. Perceived benefits included: increased awareness about PA, staff cohesion, and improved well-being. However, staff felt the APC had limited effect due to implementation barriers, including: a lack of engagement, time, resources, and funding.

CONCLUSION

This is the first evaluation of any nationwide UK-based initiative engaging GP practices in promoting PA. Acknowledging the limitations in response rate, although support exists for the RCGP APC, the evaluation highlights challenges to its implementation. Nonetheless, the wide reach of the RCGP, combined with the cited staff and patient benefits, demonstrates the significant potential of the APC initiative. Given the need to address physical inactivity nationally, further development the APC offers a possible solution, with further research required to overcome the challenges to implementation.

The Role of Intermediaries in Connecting Community-Dwelling Adults to Local Physical Activity and Exercise: A Scoping Review

Introduction

Connecting inactive individuals to local physical activity (PA) and exercise, via intermediaries (professionals who can facilitate and support connections to non-medical services) may be an effective method to tackle physical inactivity. Evidence regarding the processes of intermediaries, the profile of people referred, how connections to local PA and exercise are made and outcomes of these connections is lacking.

Methods

This scoping review followed guidelines from the Joanna Briggs Institute. Searches of four electronic databases (Embase, Medline, Web of Science, CINAHL) and an extensive grey literature search were conducted from inception to June 2022. Full-text studies which reported on community-dwelling adults (population), and the processes of intermediaries (concept) when connecting to local PA and exercise (context) were considered for inclusion. A logic model was created to map processes to outcomes. Evidence advances and gaps were identified.

Results

N = 28 studies were identified. Participants referred to an intermediary were older, female, and with poorer health. Where possible, the processes of referral, assessment, follow-up and discharge by intermediaries were described, as well as the local PA and exercise services used. Short-term PA outcomes appeared positive after working with intermediaries, but many studies were poorly described, and the review was not designed to examine effectiveness of this intervention.

Discussion/Conclusion

Many aspects of the processes were poorly described. More robust studies evaluating the processes of intermediaries are needed, as well as further exploration of the optimum processes in improving PA outcomes.

Implementation determinants of physical activity interventions in primary health care settings using the TICD framework: a systematic review

BACKGROUND

Translation into practice of effective physical activity interventions in primary care is difficult, due to a complex interaction of implementation determinants. We aimed to identify implementation barriers and facilitators of four primary care interventions: physical activity assessment, counselling, prescription, and referral.

METHODS

A systematic review of qualitative, quantitative and mixed-methods studies published since 2016 was conducted. The "Tailored Implementation for Chronic Diseases" (TICD) framework was adapted to extract and synthesize barriers and facilitators.

RESULTS

Sixty-two studies met the inclusion criteria. Barriers (n = 56) and facilitators (n = 55) were identified across seven domains, related to characteristics of the intervention, individual factors of the implementers and receivers, organizational factors, and political and social determinants. The five most frequently reported determinants were: professionals' knowledge and skills; intervention feasibility/compatibility with primary health care routine; interventions' cost and financial incentives; tools and materials; and professionals' cognitions and attitudes. "Social, political and legal factors" domain was the least reported. Physical activity counselling, prescription, and referral were influenced by determinants belonging to all the seven domains.

CONCLUSION

The implementation of physical activity interventions in primary care is influenced by a broader range of determinants. Barriers and facilitators related with health professionals, intervention characteristics, and available resources were the most frequently reported. A deep understanding of the local context, with particularly emphasis on these determinants, should be considered when preparing an intervention implementation, in order to contribute for designing tailored implementation strategies and optimize the interventions' effectiveness.

Self-perception of primary health-care staff about physical activity on prescription: A qualitative semi-structured interview

OBJECTIVE

This study aimed to analyze the self-perception at primary health-care (PHC) nurses and general practitioners (GPs) toward PAP implementation in PHC centers.

MATERIAL AND METHODS

Two semi-structured group interviews were performed separately, with five GPs and nurses working in the PHC system in the region of Madrid (Spain). An expert psychologist guided each semi-structured session. The interviews were transcribed verbatim and consensually analyzed using a content analysis.

RESULTS

Half of the PHC staff considered themselves physically active and were convinced that physically active staff behavior could facilitate PAP with patients. Both GPs and nurses showed a lack of knowledge of exercise prescription but were interested in PAP and motivational training courses, as well as leadership or to collaborate under a multidisciplinary or interdisciplinary PAP approach. Some of the most relevant self-perceived PAP barriers were a confident method to measure sedentary and physical activity levels. Besides lack of staff awareness, time of consultation, and improving local community relationships and PAP policies strategies.

CONCLUSIONS

There are some common self-perceptions, barriers, and facilitators among PHC nurses and GPs for PAP implementation. Following a socio-ecologic approach, this organizational data provides further insight to design a future cost-effective policy strategy to improve patient health and health-care system sustainability.

Implementation of the EIRA 3 Intervention by Targeting Primary Health Care Practitioners: Effectiveness in Increasing Physical Activity

The World Health Organization (WHO) estimated that physical inactivity (PI) is responsible for 20 to 30% of all non-communicable diseases. We aimed to analyze the effectiveness of a multiple health behavior change (MHBC) intervention to increase physical activity (PA) in patients 45 to 75 years old who had at least 2 of 3 unhealthy behaviors (tobacco use, reduced fruit and vegetable consumption, and insufficient PA). The MHBC intervention is based on the Transtheoretical Model and the conceptual framework of the "5 A's" and includes an individually tailored intervention, group sessions, and the use of community resources. We included 3062 participants, 1481 in the intervention group and 1581 in the control group. After 12 months, there were no differences in PA intensity measured by metabolic_equivalent_of_task_minutes/week (adjusted mean difference: 284.093, 95% CI: -298.24, 866.42) nor in the proportion of participants who increased PA levels to moderate or high (OR: 1.02, 95% CI: 0.85, 1.23; p = 0.822), and no differences in blood pressure, weight loss, or waist circumference. We found an increased proportion of patients in the intervention group who followed the WHO recommendations for PA (OR: 1.29; 95% CI: 1.04, 1.60; p = 0.02). We concluded that the intervention did not lead to a significant increase in PA.

A multilevel transition perspective on embedding intersectoral action in local health policies

Intersectoral action is advocated as a social practice that can effectively address health inequalities and related social issues. Existing knowledge provides insight into factors that may facilitate or hinder successful intersectoral action, but not much is known about how intersectoral action evolves and becomes embedded in local health policies. This is where this study aims to make its contribution, by adopting the multilevel perspective on transitions, which is increasingly used to study social innovation in sustainability transitions but has not yet been applied to public health and health promotion. Through this perspective, it was unravelled how intersectoral action between youth-care organizations and community sports clubs became embedded in local health policies of Rotterdam, a large city in the Netherlands. A single explorative case study was conducted based on content analysis of policy documents and 15 in-depth interviews with policy officers, managers and field workers operating in the fields of youth and sports in Rotterdam. The findings showed that intersectoral action between community organizations and policymakers evolves through congruent processes at different levels that changed institutional logics. Moreover, it emerged that policymakers and other actors that advocate novel social practices and act as boundary spanners can adopt multiple strategies to embed these practices in local health policy. The multi-level perspective adds value to earlier approaches to research intersectoral collaboration for health promotion as it allows to better capture the politics involved in the social innovation processes. However, further sharpening and more comprehensive application of transition concepts to study transitions in public health and health promotion is needed.

How to recruit inactive residents for lifestyle interventions: participants' characteristics based on various recruitment strategies

Care Sport Connectors (CSCs) have been appointed to create a connection between primary care and physical activity (PA) sectors to stimulate inactive residents into becoming physically active. Adequate recruitment strategies are necessary to reach the intended target group in order to foster the sustainability of lifestyle interventions. The objective of this study is to explore PA behavior and health characteristics of the target group reached by CSCs and if these characteristics differ between participants when grouped based on how they were recruited. Participants from lifestyle interventions were included between September 2014 and April 2016 using a purposive sampling method. Participants were recruited through CSCs via public relations (n = 135), a personal letter (n = 136), or a referral (n = 98) and compared based on their PA level, health-related quality of life, motivation, self-efficacy, morbidity and health-related fitness. Scores were analyzed with a multi-level (mixed model) analysis measured before the intervention. The three groups were different in PA level (p = 0.002). The outcomes regarding health-related quality of life, motivation, and number of somatic disorders were also significantly different for the three groups, except for the categories of mental health (p = 0.145) and self-efficacy (p = 0.464). For all dimensions, the referral group scored the least favorable. The investment in time and money for an active recruitment strategy like referrals is worthwhile because it provides CSCs the opportunity to reach people who are inactive and at risk of chronic disease. Future studies are necessary to reveal the effect on PA levels and health in the long-term.

The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews

BACKGROUND

Policymakers in many countries promote collaboration between health care organizations and other sectors as a route to improving population health. Local collaborations have been developed for decades. Yet little is known about the impact of cross-sector collaboration on health and health equity.

METHODS

We carried out a systematic review of reviews to synthesize evidence on the health impacts of collaboration between local health care and non-health care organizations, and to understand the factors affecting how these partnerships functioned. We searched four databases and included 36 studies (reviews) in our review. We extracted data from these studies and used Nvivo 12 to help categorize the data. We assessed risk of bias in the studies using standardized tools. We used a narrative approach to synthesizing and reporting the data.

RESULTS

The 36 studies we reviewed included evidence on varying forms of collaboration in diverse contexts. Some studies included data on collaborations with broad population health goals, such as preventing disease and reducing health inequalities. Others focused on collaborations with a narrower focus, such as better integration between health care and social services. Overall, there is little convincing evidence to suggest that collaboration between local health care and non-health care organizations improves health outcomes. Evidence of impact on health services is mixed. And evidence of impact on resource use and spending are limited and mixed. Despite this, many studies report on factors associated with better or worse collaboration. We grouped these into five domains: motivation and purpose, relationships and cultures, resources and capabilities, governance and leadership, and external factors. But data linking factors in these domains to collaboration outcomes is sparse.

CONCLUSIONS

In theory, collaboration between local health care and non-health care organizations might contribute to better population health. But we know little about which kinds of collaborations work, for whom, and in what contexts. The benefits of collaboration may be hard to deliver, hard to measure, and overestimated by policymakers. Ultimately, local collaborations should be understood within their macro-level political and economic context, and as one component within a wider system of factors and interventions interacting to shape population health.

Connecting primary care patients to community-based physical activity: a qualitative study of health professional and patient views

Background

Inconclusive evidence supporting referrals from health professionals to gym-based exercise programmes has raised concern for the roll-out of such schemes, and highlights the importance of developing links between healthcare settings and community-based opportunities to improve physical activity (PA) levels.

Aim

This study aimed to identify methods, and explore barriers and facilitators, of connecting primary care patients with PA opportunities from the perspectives of both health professionals (HPs) and patients, using the example of jogscotland.

Design & setting

An exploratory study utilising semi-structured interviews with primary care patients (n = 14) and HPs (n = 14) from one UK NHS board was conducted.

Method

Patient and HP transcripts were analysed separately using thematic analysis. Potential methods of connection were identified. The Capability, Opportunity, Motivation, behavioural (COM-B) model and theoretical domains framework (TDF) were employed to facilitate identification of barriers and facilitators for connecting primary care to community jogscotland groups.

Results

Three methods of connecting patients to community-based groups were identified: informal passive signposting, informal active signposting, and formal referral or prescribing. Barriers and facilitators for patient connection fell into five TDF domains for HPs and two COM-B model components for patients.

Conclusion

For patients, HPs raising the topic of PA can help to justify, facilitate, and motivate action to change. The workload associated with connecting patients with community-based opportunities is central to implementation by HPs. Integrative resource solutions and social support for patients can provide a greater variety of PA options and the vital information and support for connecting with local opportunities, such as jogscotland.

Perceptions of Care Sport Connectors' Tasks for Strengthening the Connection Between Primary Care, Sports and Physical Activity: A Delphi Study

INTRODUCTION

Care sport connectors stimulate physical activity and facilitate collaboration between the primary care and physical activity sectors in the Netherlands. To strengthen intersectoral collaboration between the primary care and sports sectors, it is necessary to study which tasks a care sport connector must fulfil according to their own and other professionals' perceptions.

METHODS

A Delphi study was conducted with 182 professionals from the primary care, public health and physical activity sectors. Rounds 1 and 2 included questions about task perception, willingness to collaborate and expectations of care sport connectors. Rounds 3 and 4 were used to reach consensus.

RESULTS

All professions acknowledged physical activity promotion tasks, but they are not all willing to collaborate. They expect a broad range of roles from care sport connectors: informative, executive, guiding and intermediate. Care sport connectors reached consensus on two roles: informative and intermediate.

DISCUSSION

Care sport connectors have an important role in strengthening intersectoral collaboration. All the professions acknowledged a task concerning physical activity promotion and accepted a broker role. Thus, a public health mind-set seems to be present to some extent. However, challenges remain, such as the lack of willingness to collaborate among primary care professionals and sports policies not (yet) supporting intersectoral collaboration.

The implementation of a physical activity counseling program in rehabilitation care: findings from the ReSpAct study

PURPOSE

This study aimed to evaluate the implementation of a physical activity counseling program in rehabilitation and to study heterogeneity in received counseling and investigate its association with changes in patients' physical activity outcomes.

METHODS

This prospective cohort study was conducted in 18 rehabilitation institutions. Data were collected using surveys completed by professionals (n= ±70) and patients (n = 1719). Implementation was evaluated using different process outcomes: reach, dosage, satisfaction, maintenance. Patients' physical activity outcomes included changes in total minutes/week of physical activity. Latent class analyses were conducted to identify profiles of received counseling characteristics and multilevel models were used to investigate associations with physical activity outcomes.

RESULTS

5873 Patients were provided with motivational interviewing-based counseling after rehabilitation. Professionals and patients were positive about the program. Sixteen institutions (89%) formally agreed to continue the program. The four identified profiles of counseling characteristics illustrate a large variation in received counseling among patients. No substantial differences in physical activity outcomes were found between profiles.

CONCLUSION

After a three-year program period, the physical activity counseling centers were sustainably implemented in Dutch rehabilitation care. This study illustrated an innovative approach to assess heterogeneity in implementation outcomes (e.g., counseling profiles) in relation to program outcomes (e.g., physical activity).Implications for rehabilitationPhysical activity counseling after rehabilitation is important to support people with disabilities in making the step from rehabilitation-based physical activities to community-based physical activities.Establishing "Physical Activity Counseling Centers" is a promising "disability-overarching" strategy to promote physical activity after rehabilitation.Although the actual received counseling (dosage) varied among patients, this did not coincide with large differences in physical activity outcomes.The training in Motivational Interviewing, the financial incentives, and the advisory support were considered as important or essential ingredients for a successful implementation of the counseling program in rehabilitation practice.

Physical activity promotion in primary care: a Utopian quest?

The health benefits of physical activity (PA) are acknowledged and promoted by the scientific community, especially within primary care. However, there is little evidence that such promotion is provided in any consistent or comprehensive format. Brief interventions (i.e. discussion, negotiation or encouragement) and exercise referral schemes (i.e. patients being formally referred to a PA professional) are the two dominant approaches within primary care. These cost-effective interventions can generate positive changes in health outcomes and PA levels in inactive patients who are at increased risk for non-communicable diseases. Their success relies on the acceptability and efficiency of primary care professionals to deliver PA counselling. To this end, appropriate training and financial support are crucial. Similarly, human resourcing and synergy between the different stakeholders must be addressed. To obtain maximum adherence, specific populations should be targeted and interventions adapted to their needs. Key enablers include motivational interviewing, social support and multi-disciplinary approaches. Leadership and lines of accountability must be clearly delineated to ensure the success of the initiatives promoting PA in primary care. The synergic and multisectoral action of several stakeholders, especially healthcare professionals, will help overcome physical inactivity in a sustainable way.

Short-and Long-Term Effectiveness of a Physical Activity Intervention with Coordinated Action between the Health Care Sector and Local Sports Clubs. A Pragmatic Trial in Austrian Adults

(1) Background: Collaboration between the health care sector and the sports sector to increase physical activity (PA) behaviour among inactive adults is still rare. The objective of the study was to evaluate the short- and long-term effectiveness of a mixed PA intervention on the PA behaviour in an adult population. (2) Methods: In a quasi-experimental study with two follow-up measurements (four and 12 months), adults were contacted by post before their stay in a health resort. During the health resort stay, the intervention group (IG) received PA counselling and a coupon for 12 standardised free-of-charge sessions in a sports club. The participants in the comparator group (CG) received PA counselling and written material. PA was measured with an accelerometer (GENEActive). Linear mixed-effects models were applied to examine the change in PA behaviour, both within and between groups in moderate- to vigorous-intensity PA over time. (3) Results: We obtained at least one follow-up measurement from 217 participants (IG = 167, CG = 50), who were 50% female, with an average age of 53 (±6) years. PA significantly increased from the baseline to the four-month measurement by 58 min./wk (95% CI 36, 80) and to the 12-month measurement by 24 min./wk (95% CI 2, 46) within the IG. No change in PA occurred in the CG. We also found a short-term between-group (IG vs. CG) difference in change over time, but not a long-term difference. (4) Conclusions: The study confirms that a collaboration between the health care sector and local sports clubs is a feasible method of recruiting people into a standardised PA programme and to increase their PA over the long term.

Study protocol: evaluation of a community health promotion program in a socioeconomically deprived city district in the Netherlands using mixed methods and guided by action research

BACKGROUND

Voorstad on the Move (VoM) is a community health promotion program implemented in a socioeconomically deprived city district in the Netherlands. Based on exploration of the health situation, concurrent views on health promotion, and insights from literature, VoM is grounded in a social-ecological perspective and puts three action principles center core: citizens' participation, intersectoral collaboration, and a health supportive environment. VoM aims to improve the health of inhabitants, mostly low socioeconomic status (SES) families, and to realize changes in the social and physical environment. This current research, as part of the wider VoM project, aims to study the impacts and action principles of VoM. The main research questions concern the inhabitants' perceptions on health and health supportive environments, the perceived benefits of citizen participation in terms of health literacy and empowerment, and the factors and mechanisms that contribute to citizen participation and intersectoral collaboration.

METHODS

The study has a mixed methods design, including process evaluation and monitoring, and combines qualitative and quantitative data. Research activities include literature study, in-depth interviews, focus group discussions, concept and capacity mapping, document analysis, and health survey data. A prominent strategy is action research, which aims to involve all stakeholders, capturing the different perspectives of citizens and professionals, and engaging low SES groups. The principle of triangulation is continuously applied to optimize the reliability of this study, using multiple methods and multiple sources. Internal validity is enhanced by triangulation of methods and resources. Other verification techniques will also be used, such as expert consultation.

DISCUSSION

The design of the study, with a strong focus on action research, facilitates the involvement of all stakeholders and contributes to the development of capacities, learning, and empowerment, and thus contributes to health. The VoM program is innovative because it adopts an open approach in which activities evolve from citizens' needs, with a focus on action elements. This study will unravel the mechanisms of the action elements at community level, thereby helping to find ways to reduce health inequities. The findings will further elucidate what works and why it works for low SES groups.

Exploring the impact of the care sport connector in the Netherlands

BACKGROUND

Regular physical activity (PA) is deemed to contribute to the primary and secondary prevention of several chronic diseases, like diabetes mellitus, cancer, cardiovascular diseases, and osteoporosis. In 2012, Care Sport Connectors (CSC), to whom a broker has been ascribed, were introduced in the Netherlands to stimulate PA and guide primary care patients towards local sport facilities. The aim of this study was to explore which structural embedding is the most promising for CSCs' work.

METHODS

In three rounds of interviews, 13 CSCs were followed for 2 years in their work. In these interviews, a network survey was used to identify organisations in the CSCs' network, whether they collaborated with these organisations, and the role of the organisations in the connection. Data from the network survey were analysed using the RE-AIM framework and disaggregated into how CSCs were structurally embedded (Type A: only PA sector; Type B: different sectors; Type C: partnership). A related samples Wilcoxon signed rank test was performed to study how the CSCs' network developed between 2014 and 2016.

RESULTS

All CSCs established a connection between the primary care and the PA sector in which the average number of organisations with which CSCs collaborated increased significantly between 2014 (8.3) and 2016 (19.8) (p = 0.002). However, differences were identified in the way CSCs were structurally embedded and in the way they established the connection. Type A CSCs established the connection mostly around their own activities, supported PA organisations with their activities, and collaborated with primary care and welfare professionals around their own activities. Type B and Type C CSCs established the connection by organising, supporting, and implementing different kinds of activities targeting different kinds of audiences, and collaborated mostly with primary care professionals around the referral of professionals' patients.

CONCLUSIONS

The results of this study suggest that adopting an integral approach (Type B and C) for the structural embedding of the CSC is more promising for reaching the desired outcomes. Whether CSCs really improve the target groups' PA level and health needs to be further studied.

TRIAL REGISTRATION

Dutch Trial Register NTR4986 . Registered 14 December 2014.