Patients' experiences of physical activity on prescription with access to counsellors in routine care: a qualitative study in Sweden

Leisure-time physical activity, desire to increase physical activity, and mortality: A population-based prospective cohort study

The aim was to investigate associations between leisure-time physical activity (LTPA) and mortality, and associations between desire to increase LTPA and mortality within the low LTPA group. A public health survey questionnaire was sent in 2008 to a stratified random sample of the population aged 18-80 in southernmost Sweden, yielding a 54.1% response rate. Baseline 2008 survey data with 25,464 respondents was linked to cause of death register data to create a prospective cohort with 8.3-year follow-up. Associations between LTPA, desire to increase LTPA and mortality were analyzed in logistic regression models. An 18.4% proportion performed regular exercise (at least 90 min/week, leading to sweating), 23.2% moderate regular exercise (once or twice a week at least 30 min/occasion, leading to sweating), 44.3% moderate exercise (more than two hours walking or equivalent activity/week) and 14.1% reported low LTPA (less than two hours walking or equivalent activity/week). These four LTPA groups were significantly associated with covariates included in the multiple analyses. The results showed significantly higher all-cause, cardiovascular (CVD), cancer and other cause mortality for the low LTPA group but not for the moderate regular exercise and moderate exercise groups compared to the regular exercise group. Both the "Yes, but I need support" and the "No" fractions within the low LTPA group had significantly increased ORs of all-cause mortality compared to the "Yes, and I can do it myself" reference, while no significant associations were observed for CVD mortality. Physical activity promotion is particularly warranted in the low LTPA group.

Cost-Effectiveness of Prolonged Physical Activity on Prescription in Previously Non-Complying Patients: Impact of Physical Activity Mediators

In Sweden, physical activity on prescription (PAP) is used to support patients in increasing their levels of physical activity (PA). The role of healthcare professionals in supporting PA behavior change requires optimization in terms of knowledge, quality and organization. This study aims to evaluate the cost-effectiveness of support from a physiotherapist (PT) compared to continued PAP at a healthcare center (HCC) for patients who remained insufficiently active after 6-month PAP treatment at the HCC. The PT strategy was constituted by a higher follow-up frequency as well as by aerobic physical fitness tests. The analysis was based on an RCT with a three-year time horizon, including 190 patients aged 27-77 with metabolic risk factors. The cost per QALY for the PT strategy compared to the HCC strategy was USD 16,771 with a societal perspective (including individual PA expenses, production loss and time cost for exercise, as well as healthcare resource use) and USD 33,450 with a healthcare perspective (including only costs related to healthcare resource use). Assuming a willingness-to-pay of USD 57,000 for a QALY, the probability of cost-effectiveness for the PT strategy was 0.5 for the societal perspective and 0.6 for the healthcare perspective. Subgroup analyses on cost-effectiveness based on individual characteristics regarding enjoyment, expectations and confidence indicated potential in identifying cost-effective strategies based on mediating factors. However, this needs to be further explored. In conclusion, both PT and HCC interventions are similar from a cost-effectiveness perspective, indicating that both strategies are equally valuable in healthcare's range of treatments.

The effects of a 5-year physical activity on prescription (PAP) intervention in patients with metabolic risk factors

BACKGROUND

Increased physical activity (PA) has positive effects on health and longevity. In Swedish healthcare, the physical activity on prescription (PAP) method reportedly increases patients' PA levels for up to 12 months, but long-term follow ups are lacking. As it remains difficult to maintain lifestyle changes, our aim was to evaluate adherence and clinical effects at a 5-year follow-up of PAP treatment in primary healthcare.

METHODS

This longitudinal, prospective cohort study included 444 patients, (56% female), aged 27-85 years, with at least one metabolic risk factor. Participants were offered PAP by nurses or physiotherapists. The PAP intervention included an individualised dialogue, a PA recommendation by written prescription, and individually adjusted follow-up over 5 years, according to the Swedish PAP model. Patient PA level, metabolic risk factors, and health related quality of life (HRQoL) were measured at baseline and at the 6-month, 1.5-year, 2.5-year, 3.5-year, and 5-year follow-ups. Estimated latent growth curves were used to examine levels and rates of change in the outcomes.

RESULTS

The study dropout rate was 52%, with 215 of 444 patients completing the 5-year follow-up. At follow-up, the mean PA level had increased by 730 MET-minutes per week or 3 hours of moderate-intensity PA/week when compared to baseline. During the 5-year intervention, we observed significant positive changes (p ≤ 0.05) in 9 of 11 metabolic risk factors and HRQoL parameters: body mass index, waist circumference, systolic and diastolic blood pressure, fasting plasma glucose, triglycerides, cholesterol, high-density lipoprotein, and mental component summary.

CONCLUSION

This first evaluation of a 5-year PAP intervention in primary care demonstrated positive long-term (5 years) effects regarding PA level, metabolic health, and HRQoL. The recorded long-term adherence was ~50%, which is in line with medical treatment. Despite limitations, PAP can have long-term effects in an ordinary primary care setting.

Factors associated with increased physical activity among patients prescribed physical activity in Swedish routine health care including an offer of counselor support: a 1-year follow-up

BACKGROUND

The study addresses knowledge gaps in research regarding influences of routine health care delivery of physical activity on prescription (PAP). The aim was to investigate if patient and health care characteristics are associated with increased physical activity 1 year after prescription among patients offered counselor support in addition to health care professionals' prescription. The study was conducted in primary and secondary care in a Swedish health care region.

METHODS

All PAP recipients during 1 year were invited (N = 1503) to participate in this observational prospective study. Data were collected from medical records and questionnaires (baseline and follow-up). Descriptive statistics and multiple logistic regression analysis were used. The outcome variable was increased physical activity after 1 year. Study variables were patient and health care characteristics.

RESULTS

Three hundred and fifty-five patients with complete follow-up data were included. The mean age was 62 years (SD = 14; range, 18-90) and 68% were females. Almost half (47%) had increased physical activity 1 year after PAP. Multiple logistic regression analysis showed that increased physical activity at follow-up was positively associated with lower baseline activity, counselor use, and positive perception of support. Counselor users with low baseline activity had higher odds ratio for increased physical activity at follow-up than non-users (OR = 7.2, 95% CI = 2.2-23.5 vs. OR = 3.2, 95% CI = 1.4-7.5). Positive perception of support was associated with increased physical activity among counselor users but not among non-users.

CONCLUSIONS

An increase in physical activity after PAP was related to low baseline activity, positive perception of support, and use of counselor support after PAP. Qualified counseling support linked to PAP seems to be important for achieving increased physical activity among patients with lower baseline activity.

Identifying the factors affecting 'patient engagement' in exercise rehabilitation

Background

Despite the proven benefits of exercise rehabilitation for numerous health conditions, musculoskeletal injuries and recovery from surgery, patient adherence to such programs is reported to often be less than 35%. Increasing patient engagement therefore has the potential to improve patient health outcomes, benefiting the patient, their carers and the services that support them. The aims of this review were to identify the factors that contribute to ‘patient’ engagement in prescribed exercise rehabilitation using the COM-B (capability, opportunity, motivation-behaviour) framework of behavioural analysis.

Methods

Five electronic databases (PubMed, Embase, Cochrane, Web of Science, and ClinicalTrials.gov) were searched. ‘COM-B’ was the key word searched for specifically within titles and abstracts, combined with either ‘physical activity’ OR ‘exercise’ included using the ‘AND’ operation. Records were then filtered and excluded following full-text screening based on the predetermined eligibility criteria.

Results

Twenty studies were included in the review. The main COM-B themes highlighted for improving patient engagement were: capability—improving patient knowledge and cognitive skills for behavioural regulation, such as ‘action planning’ and ‘action control’, which could also benefit time-management; opportunity—a balanced life situation that enabled time to be devoted to the exercise program, social support, easily accessible and affordable resources and services; and motivation—increasing patient levels of self-efficacy and autonomous motivation, which were noted to be influenced by levels of perceived ‘capability’, additionally ‘motivation’ was noted to be influenced by patients perceiving the benefits of the exercise, and adherence to the program was promoted by ‘goal-setting’. Other issues in the ‘capability’ domain included a fear and/or dislike of exercise.

Conclusion

Patient engagement behavior has been shown to be influenced by both external (opportunity) and intrapersonal variables (capability and motivation). Those prescribing exercises within a rehabilitation program need to discuss these factors with their patients and co-design the exercise rehabilitation program in partnership with the patient, since this is likely to improve patient engagement, and thereby result in superior health outcomes. Furthermore, these factors need to be a consideration in clinical trials, if the findings from such trials are to translate into mainstream healthcare settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-022-00407-3.

Socioecological Factors Associated with an Urban Exercise Prescription Program for Under-Resourced Women: A Mixed Methods Community-Engaged Research Project

One strategy to promote physical activity (PA) is for health care providers to give exercise prescriptions (ExRx) that refer to community-based facilities. However, facilitators and barriers specific to urban programs in the US for under-resourced women are unknown. Thus the purpose of this formative research was to explore ExRx barriers and facilitators specific to US under-resourced women to inform future intervention targets and strategies. This mixed-methods community-engaged research was conducted in partnership with an urban women's only wellness center that exchanged ExRx for free access (1-3 months). Qualitative semi-structured interviews and validated quantitative questionnaires (SF-12, International Physical Activity Questionnaire, Physical Activity Self-Efficacy, Physical Activity Stage of Change, and Barriers to Physical Activity, Social Support for Exercise, and Confusion, Hubbub, and Order Scale) were administered by phone and guided by the socio-ecological model. ExRx utilization was defined as number visits/week divided by membership duration. Means and percentages were compared between ≥1 visit/week vs. <1 visit/week with t-tests and chi-square, respectively. Women (n = 30) were 74% Black, 21-78 years of age, 50% had ≤ high school diploma, and 69% had household incomes ≤45,000/year. Women with ≥1 visit/week (n = 10; 33%) reported more education and higher daily activity, motivation, number of family CVD risk factors and family history of dyslipidemia compared with <1 visit/week. Facilitators among women with ≥1 visit/week were "readiness" and "right timing" for ExRx utilization. Barriers among women with <1 visit/week (n = 20; 67%) were "mismatched expectations" and "competing priorities". Common themes among all women were "sense of community" and "ease of location". ExRx utilization at an US urban wellness center may be dependent on a combination of multi-level factors including motivation, confidence, peer support, location and ease of access in under-sourced women. Additional resources may be needed to address mental and/or physical health status in additional to physical activity specific programming.

Tailored physical activity on prescription with follow-ups improved motivation and physical activity levels. A qualitative study of a 5-year Swedish primary care intervention

OBJECTIVE

To explore how physically inactive patients, with metabolic risk factors, experienced long term treatment with physical activity on prescription.

DESIGN

Qualitative content analysis of individual interviews after strategical sampling of respondents.

SETTING

Fifteen primary health care centres in Gothenburg, Sweden.

SUBJECTS

Twenty physically inactive patients, with one or more metabolic syndrome components, 9 women, 11 men, mean age 58 years (25-73); 10 patients were responders and 10 non-responders to the intervention.

MAIN OUTCOME MEASURES

Categories describing treatment effect and successful intervention.

RESULTS

The interviews revealed three categories of effect. First, individual adjustments contributed to increased physical activity. Second, follow-up and support were valuable aids for prioritising and maintaining lifestyle changes. Third, motivation could be higher if patients make their own choices and experienced positive health effects. The overarching emerging theme was 'tailored physical activity on prescription with regular follow-ups can contribute to increased and maintained motivation and physical activity levels.'

Conclusion Physical activity on prescription in a Swedish primary care setting was successful when the recommended physical activity and follow up was individually adapted. KEY POINTS Individually adapted physical activity on prescription gave insight to increase physical activity levels in a 5-year Swedish primary care intervention directed towards inactive patients with the metabolic syndrome Motivation increased for patients designing their own routines for physical activity. Experiences of positive health effects helped maintain or increase physical activity levels, and follow-up and support from healthcare professionals helped to prioritise life style changes.

Experiences of tobacco cessation including a prescription approach among patients in Swedish primary health care with a focus on socioeconomically disadvantaged areas

Background

Tobacco Cessation on Prescription (TCP) is a new intervention that is being evaluated in socioeconomically disadvantaged areas in Swedish primary health care (PHC). Patients’ perceptions of TCP are important to understand as this may have implications for the acceptability and adherence to treatment and explain cessation outcomes. Patients’ general experiences of tobacco cessation are also important to explore to improve cessation support in this setting.

Aim

To explore experiences of tobacco cessation and TCP among patients in Swedish PHC focusing on socioeconomically disadvantaged areas.

Methods

Inductive content analysis of transcripts from eight semi-structured interviews with patients recruited from the intervention group in a randomized controlled trial evaluating the effectiveness of TCP in socioeconomically disadvantaged areas in PHC in Stockholm.

Results

Two themes were identified: needing individualized support to quit, taking differences in patients’ experiences of tobacco use and cessation into account, acknowledging individual factors such as impact of health and wellbeing on tobacco use and differing attitudes towards tobacco and cessation and needing a supportive environment to facilitate tobacco cessation, taking contextual factors like professional support from the health care system, the importance of the social environment and supportive societal structures into account. Regarding TCP, the prescription form was perceived as useful for providers but did not appear to have a direct impact on tobacco cessation from the informants’ perspective. However, individualized counseling from a tobacco cessation specialist, an empathetic approach in the treatment and long-term follow-up was considered important.

Conclusion

A holistic approach may be needed in cessation treatment, combined with interventions outside the health care system, to facilitate tobacco cessation among patients in socioeconomically disadvantaged areas in Swedish PHC. The TCP prescription form may be helpful for PHC providers but counseling and follow-up appear to be the most important components of TCP for patients in this setting.

Long-term physical activity on prescription intervention for patients with insufficient physical activity level-a randomized controlled trial

BACKGROUND

Physical activity (PA) can be used to prevent and treat diseases. In Sweden, licensed healthcare professionals use PA on prescription (PAP) to support patients to increase their PA level. The aim of this randomized controlled trial was to evaluate a 2-year intervention of two different strategies of PAP treatment for patients with insufficient PA level, after a previous 6-month period of ordinary PAP treatment in a primary health care setting.

METHODS

We included 190 patients, 27-77 years, physically inactive with metabolic risk factors where the patients were not responding to a previous 6-month PAP treatment with increased PA. The patients were randomized to either enhanced support from a physiotherapist (PT group) or continued ordinary PAP treatment at the health care centre (HCC group). The PAP treatment included an individualized dialogue; an individually dosed PA recommendation, including a written prescription; and a structured follow-up. In addition to PAP, the PT group received aerobic fitness tests and more frequent scheduled follow-ups. The patient PA level, metabolic health, and health-related quality of life (HRQOL) were measured at baseline and at 1- and 2-year follow-ups.

RESULTS

At the 2-year follow-up, 62.9% of the PT group and 50.8% of the HCC group had increased their PA level and 31.4% vs. 38.5% achieved ≥ 150 min of moderate-intensity PA/week (difference between groups n.s.). Over 2 years, both groups displayed increased high-density lipoproteins (HDL) (p = 0.004 vs. baseline), increased mental health status (MCS) (p = 0.036), and reduced body mass index (BMI) (p = 0.001), with no difference between groups.

CONCLUSION

During long-term PAP interventions, the PA level, metabolic health, and HRQOL increased in patients at metabolic risk without significant differences between groups. The results indicate to be independent of any changes in pharmacological treatment. We demonstrated that the PAP treatment was feasible in ordinary primary care. Both the patients and the healthcare system benefitted from the improvement in metabolic risk factors. Future studies should elucidate effective long-term PAP-treatment strategies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03012516 . Registered on 30 December 2016-retrospectively registered.

Physical Activity on Prescription in Routine Health Care: 1-Year Follow-Up of Patients with and without Counsellor Support

The effectiveness of counsellor support in addition to physical activity on prescription (PAP) from health care professionals has rarely been evaluated. This observational follow-up study investigated differences in physical activity levels and health-related quality of life (HRQoL) one year after PAP regarding patients’ use of counsellor support in addition to PAP in routine care. The study was conducted in a Swedish health care region in which all patients receiving PAP from health care professionals were offered counsellor support. Data were collected from medical records and questionnaires (baseline and follow-up). Of the 400 study participants, 37% used counsellor support. The group of counsellor users attained a higher level of physical activity one year after receiving PAP compared to the group of non-users (p < 0.001). The level of physical activity was measured by a validated index (score 3–19) calculated from weekly everyday activity and exercise training. Comparison of the change in scores between baseline and follow-up showed a significant difference between the two groups, (p < 0.001). The median difference in the PAP + C group was 2.0 (interquartile range, 7.0) and 0.0. among non-users (interquartile range, 4.0). Significant differences in HRQoL were due to positive improvements among counsellor users, with the main improvement in general health. The conclusion is that patients using counsellor support after receiving PAP from health care professionals had higher physical activity and better HRQoL one year after compared with patients who did not use this support.

Physical Activity Counseling in Primary Care in Germany-An Integrative Review

Physical activity counseling in primary health care is regarded as a useful complementary preventive and therapeutic measure and is advocated by leading public health institutions. This integrative review summarizes the available data on physical activity counseling in primary care in Germany. A systematic literature search in various databases (peer reviewed and grey literature) was carried out for quantitative and qualitative studies on physical activity counseling and use of "Exercise on Prescription". The 25 studies included show a very high methodological diversity and, in some cases, considerable risks of bias, with limited comparability across studies. Counseling was provided in all studies by physicians. They report frequent physical activity counseling, which is partly confirmed and partly refuted by patient data. The use of "Exercise on Prescription" is at a very low level. Information on the frequency of physical activity counseling in Germany varies depending on data source and is sometimes contradictory. Our review provides a synthesis of various perspectives on routine physical activity counseling in primary care in Germany. Future studies using standardized and validated instruments in representative samples are needed to further knowledge on counseling and to be able to establish trends in prevalence. Strengthening the topics of physical activity and health and physical activity counseling in medical curriculum is strongly recommended.

Initiation and maintenance of lifestyle changes among participants in a healthy life centre: a qualitative study

Background

Since the early 2000s, Healthy Life Centres have been established in Norway to promote physical and mental health. Yet to date, little is known about the efficacy of Healthy Life Centres in promoting health behaviour change and maintenance or the factors that underlie these processes. Accordingly, the aim of the current study was to examine the factors that participants in a Healthy Life Centre perceive as relevant for the initiation and maintenance of lifestyle changes toward more physical activity and consumption of a healthier diet.

Method

Participants were purposely recruited from among adherers in a 12-month multi-method research project at a Healthy Life Centre. Individual, semi-structured interviews were conducted with 8 women and 6 men who were between the ages of 20 and 61 years old. Data were analysed using Systematic Text Condensation.

Results

Three main themes were derived from this analysis. The first theme focused on the motives behind initiation and maintenance of lifestyle changes along with the importance of a relationally supportive environment to promote perceived competence in pursuing a healthy lifestyle. The second theme focused on strategies for coping with the challenges and potential pitfalls that were associated with various unpleasant experiences and life events. The third theme focused on several specific skills that were helpful to the initiation and maintenance of lifestyle changes.

Conclusion

The current study enhanced an understanding of the initiation and maintenance of lifestyle changes, although these processes were not disentangled in participants’ experiences. In line with self-determination theory, the results suggested that lifestyle change is more likely to be initiated and maintained when goals are not only achievable but also regulated with autonomous motivation and of intrinsic value. Conversely, lifestyle change is difficult to maintain when motives are external to the self. Further, cognitive and behavioural skills were valuable and necessary in coping with unpleasant emotions. Finally, the critical function of self-regulation skills for making realistic plans and prioritizations in order to balance healthy lifestyle behaviours with the routines of “daily life” while monitoring outcomes was readily apparent. Healthy Life Centres can contribute to these processes in meaningful ways.