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

Physical activity on prescription in Swedish primary care: a survey on use, views, and implementation determinants amongst general practitioners

INTRODUCTION

Swedish Physical Activity on Prescription (PAP) has been shown to increase physical activity levels, which is known to lead to positive health effects. PAP is being implemented in Swedish healthcare to various extents. However, there is a lack of knowledge about how Swedish general practitioners (GPs) work with PAP and what hinders and facilitates wider implementation.

AIMS

This study aimed to survey GPs' use and views of PAP, identify barriers and facilitators for implementing PAP, and explore associations to gender, practice location, and experience.

METHODS

The study was framed by the Normalization Process Theory. A survey was sent to 463 GPs at 69 different healthcare centres in Region Västra Götaland. Data were analysed using multiple logistic and linear regressions.

RESULTS

A total of 143 GPs completed the survey (response rate 31%). Views on PAP were generally positive amongst respondents, but only 27% reported using PAP regularly. The most prominent reported barriers were insufficient training and resources. Positive views and willingness to collaborate in using PAP were identified as facilitators. Responding GPs in Gothenburg used PAP more often (OR 6.4; 95% CI 2.7-14.8) and were significantly more positive to the method than GPs in other areas of the region. GPs with more than 10 years of practice used PAP more often (OR 2.5; 95% CI 1.1-6.0) than less experienced GPs. Few of the investigated variables were associated with gender.

CONCLUSIONS

The positive views amongst responding GPs are helpful, but more education, training and resources are needed for successful implementation of PAP in Swedish primary health care.

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.

Personalized remotely guided preventive exercise therapy for a healthy heart (PRIORITY): protocol for an assessor-blinded, multicenter randomized controlled trial

Aims

A key treatment for patients with varying stages of heart failure with preserved ejection fraction (HFpEF) is exercise. Yet, despite a Class 1A recommendation, only one-third of patients exercise sufficiently. A huge treatment gap exists between guidelines and clinical practice. PRIORITY aims to establish the feasibility, clinical effectiveness and cost-effectiveness of a hybrid centre and home-based personalized exercise and physical activity intervention for patients along the HFpEF continuum.

Methods

An assessor-blinded, multicenter randomized controlled trial will be conducted among 312 patients along the HFpEF continuum. Participants will be randomized (1:1) to the PRIORITY intervention or a comparator group receiving only a written exercise prescription. Participants in the PRIORITY group will receive 18 supervised centre-based exercise sessions during one year, supplemented with a remotely guided home-based physical activity program. Outcomes will be assessed at baseline, 4 months, one and two years. The primary outcome is the peak oxygen uptake (pVO2) at 1-year. Secondary outcomes include physical activity, other physical fitness parameters, cardiovascular health, echocardiographic parameters, health-related quality of life and costs at 1-year FU. Machine learning algorithms will analyse big data on physical activity collected during the 1-year intervention to develop models that can predict physical activity uptake and adherence as well as changes in fitness and health. A cost-utility analysis will be performed to evaluate the cost-effectiveness of the PRIORITY intervention compared to the control condition.

Discussion

We anticipate that participants in the supervised home-based exercise intervention group will have a greater increase in pVO2 compared to those receiving a written exercise prescription.

Trial registration number

This trial is registered at ClinicalTrials.gov (NCT04745013) and is currently in the recruitment stage.

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.