Exercise Referral Schemes Research Articles

Gaining qualitative insight into the subjective experiences of adherers to an exercise referral scheme: A thematic analysis.

Nine adults who had completed an exercise referral scheme participated in a semi-structured interview to uncover the key psychological factors associated with adherence to the scheme. Through thematic analysis, an exercise identity emerged to be a major factor associated with adherence to the scheme, which was formed of a number of underpinning constructs including changes in self-esteem, changes in self-efficacy and changes in self-regulatory strategies. Also, an additional theme of transitions in motivation to exercise was identified, showing participants' motivation to alter from extrinsic to intrinsic reasons to exercise during the scheme.

Combining Supervised Exercise And Physical Activity Counselling Might Increase Retention To GP Exercise Referral Programmes.

PURPOSE: Evidence for the effectiveness of GP Exercise Referral is weak (1, 2). We examined traditional supervised exercise (TRAD), physical activity counselling (PAC), combined TRAD/PAC (CMB) and wait-list controls (CON) in a community exercise referral programme in South East London, UK. METHODS: PPs (n=141) were identified by their doctors as overweight and at increased risk of Type 2 Diabetes. PPs were randomly assigned to treatment. Measures were blood pressure and body composition at baseline and 12 weeks. RESULTS: One-way ANOVA of absolute change in dependant variables between treatments indicated that body fat mass, body fat % and systolic blood pressure were reduced at 12 weeks for all groups including CONT. No statistically significant between-group effects were observed. Paired sample t-tests indicated that lean mass was significantly increased at 12 weeks for all groups including CON; diastolic blood pressure was significantly decreased for all groups at 12 weeks except PAC. Retention was highest to CMB (75%), followed by CON (68%), with PAC and TRAD both at 55%. CONCLUSIONS: Treatment groups and CON appeared to benefit from the programme, with likely measurement effects partially explaining improvement in CON. High retention to CMB is of significance to future GP Referral programmes.Table 1: Paired samples T-test comparing dependant variables at baseline and 12 weeks1. Beedie C, Mann S, Jimenez A et al. Death by effectiveness: exercise as medicine caught in the efficacy trap! BJSM. 2015. 2. Pavey T, Taylor A, Hillsdon M et al. Levels and predictors of exercise referral scheme uptake and adherence: a systematic review. J Epidemiol Community Health. 2012;66(8):737-44.

Adherence to exercise referral schemes by participants - what do providers and commissioners need to know? A systematic review of barriers and facilitators.

BackgroundPhysical inactivity levels are rising worldwide with major implications for the health of the population and the prevalence of non-communicable diseases. Exercise referral schemes (ERS) continue to be a popular intervention utilised by healthcare practitioners to increase physical activity. We undertook a systematic review of views studies in order to inform guidance from the UK National Institute of Health and Care Excellence (NICE) on exercise referral schemes to promote physical activity. This paper reports on the participant views identified, to inform those seeking to refine schemes to increase attendance and adherence.MethodsFifteen databases and a wide range of websites and grey literature sources were searched systematically for publications from 1995 to June 2013. In addition, a range of supplementary methods including, a call for evidence by NICE, contacting authors, reference list checking and citation tracking were utilised to identify additional research.Studies were included where they detailed schemes for adults aged 19 years or older who were ‘inactive’ (i.e. they are not currently meeting UK physical activity guidelines). Study selection was conducted independently in duplicate. Quality assessment was undertaken by one reviewer and checked by a second, with 20 % of papers being considered independently in duplicate. Papers were coded in qualitative data analysis software Atlas.ti. This review was reported in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement).ResultsEvidence from 33 UK-relevant studies identified that support from providers, other attendees and family was an important facilitator of adherence and ‘making exercise a habit’ post programme, as was the variety and personalised nature of sessions offered. Barriers to attendance included the inconvenient timing of sessions, their cost and location. An intimidating gym atmosphere, a dislike of the music and TV and a lack of confidence in operating gym equipment were frequently reported.ConclusionsThese findings provide valuable insights that commissioners and providers should consider. The main themes were consistent across a large number of studies and further research should concentrate on programmes that reflect these findings.

Gender perceptions and their impact when referring obese patients for exercise

Obesity trends in the UK have shown a steady increase over the past 20 years, yet differences have been identified in the uptake and adherence data for obese men and women attending exercise referral schemes (ERS). Moreover, evidence suggests that health professionals (HPs) may hold preconceived gender specific views about their patients and this has been identified as a potential barrier to male patients seeking help from their General Practitioners for chronic conditions. The aim of this paper is to examine the gender dynamics associated with health profession/patient interactions in relation to the uptake of an ERS for obese patients. The ERS in question was based in a Primary Care Health Centre in the South West of England. The respondent cohort comprised 12 patients (eight women, four men) aged 55–74 years and their six referring HPs (four women, two men). Semi-structured interviews were conducted with patients and HPs over an eight month period and the data were analysed via a grounded theory approach. The study found that HP gender specific perceptions of their patients had an impact on the methods used to encourage patients to participate. HPs typically adopted a direct interactional approach with obese men and a more cautious approach with obese women. Irrespective of gender, male and female patients found being informed of their obesity difficult to accept. The paper concludes that there is a need for a degree of care to be taken when communicating such health concerns and that this kind of approach may lead to increased ERS attendance (and adherence) by men.

Can adding web-based support to UK primary care exercise referral schemes improve patients’ physical activity levels? Intervention development for the e-coachER study.

Can adding web-based support to UK primary care exercise referral schemes improve patients’ physical activity levels? Intervention development for the e-coachER study.

Can adding web-based support to UK primary care exercise referral schemes improve patients’ physical activity levels? Findings from an internal pilot study.

Can adding web-based support to UK primary care exercise referral schemes improve patients’ physical activity levels? Findings from an internal pilot study.

Long-term engagement with a practice-based exercise referral scheme: Patients’ perceptions of effectiveness

Objectives Limited and contradictory evidence exists on the long-term effectiveness of exercise referral schemes (ERS) for physical activity promotion and its impact on perceived health status. The intention of this study was to investigate patients’ views of a physical activity intervention on their self-assessed health status.Methods A longitudinal qualitative study design was employed with 12 patients aged 55 – 74, attending a primary care physical activity intervention. Semi-structured interviews took place on three occasions over a 12 month period in a Primary Care Health Centre. Transcripts of recorded interviews were coded and thematically analysed using grounded theory techniques.Results The majority of patients believed that their engagement with the Scheme and resultant long-term increase in physical activity behaviour, helped to improve their health status. This was evident through improved perceptions of medical conditions, through stabilisation or reductions in medication and visits to medical services.Conclusion The findings show the value of a long-term physical activity intervention in a Primary Care setting, through increases in physical activity levels and patients self-assessed health status. These findings can serve as guide for future service commissioners of ERS.

A systematic review and economic evaluation of exercise referral schemes in primary care: a short report.

It is estimated that only 39% of men and 29% of women in England achieve the levels of physical activity that are recommended to protect health and prevent disease. One approach to addressing this problem has been the development of exercise referral schemes (ERSs), in which health professionals refer patients to external exercise providers. These schemes have been widely rolled out across the UK despite concerns that they may not produce sustained changes in levels of physical activity and, therefore, may not be cost-effective interventions. The evidence to determine clinical effectiveness and cost-effectiveness was evaluated in 2009. This review seeks to update this earlier work by incorporating new evidence and re-examining the cost-effectiveness. To assess the clinical effectiveness and cost-effectiveness of ERSs compared with usual care. Exhaustive searches of relevant electronic databases and journals were undertaken to identify new studies evaluating ERSs using a randomised controlled trial (RCT) design. RCTs that incorporated a qualitative evaluation of the intervention were identified in order to explore the barriers and facilitators to the uptake of and adherence to ERSs. Data were extracted using a previously designed tool and study quality assessed for potential bias. Where data could be pooled, meta-analyses were carried out. Qualitative analysis was also undertaken using a thematic approach. The cost-effectiveness was evaluated using a Markov structure which estimated the likelihood of becoming physically active and the subsequent risk reduction on coronary heart disease (CHD), stroke and type 2 diabetes mellitus. The model adopts a lifetime horizon, and a NHS and Personal Social Services perspective was taken with discounting at 1.5% for both costs and benefits. The search identified one new RCT and one new qualitative study. The new data were pooled with existing data from the 2011 review by Pavey et al. [Pavey TG, Anokye N, Taylor AH, Trueman P, Moxham T, Fox KR, et al. The clinical effectiveness and cost-effectiveness of exercise referral schemes: a systematic review and economic evaluation. Health Technol Assess 2011;15(44)] to give a total of eight studies with 5190 participants. The proportion of individuals achieving 90-150 minutes of at least moderate-intensity activity per week at 6-12 months' follow-up was greater for ERSs than usual care (relative risk 1.12; 95% confidence interval 1.04 to 1.20). Older patients and those referred for CHD risk factors appeared to be more likely than others to increase their levels of physical activity. Qualitative evidence suggests that interventions enabling the development of social support networks are beneficial in promoting uptake and adherence. Exercise referral gained 0.003 quality-adjusted life-years (QALYs) at an additional cost of £225 per person. The estimated mean incremental cost-effectiveness ratio (ICER) in the probabilistic sensitivity analysis was £76,276. In the univariate sensitivity analysis the results were very sensitive (ICERs ranged from < £30,000 to > £100,000) to changes in the effect of ERSs on physical activity uptake and the duration of the protective effects and the direct health-related quality-of-life gains attributable to physical activity. Exercise referral schemes result in a small improvement in the number of people who increase their levels of physical activity. The cost-effectiveness analysis indicates that the ICER for ERSs compared with usual care is around £76,000 per QALY, although the cost-effectiveness of ERSs is subject to considerable uncertainty. This study is registered as PROSPERO CRD42013005200. National Institute for Health Research Health Technology Assessment programme.

Health professionals' perspectives on exercise referral and physical activity promotion in primary care: Findings from a process evaluation of the National Exercise Referral Scheme in Wales.

Background and objectives:Referring clinicians’ experiences of exercise referral schemes (ERS) can provide valuable insights into their uptake. However, most qualitative studies focus on patient views only. This paper explores health professionals’ perceptions of their role in promoting physical activity and experiences of a National Exercise Referral Scheme (NERS) in Wales.Design:Qualitative semi-structured group interviews.Setting:General practice premises.Methods:Nine semi-structured group interviews involving 46 health professionals were conducted on general practice premises in six local health board areas. Purposive sampling taking into account area deprivation, practice size and referral rates was employed. Interviews were transcribed verbatim and analysed using the Framework method of thematic analysis.Results:Health professionals described physical activity promotion as important, although many thought it was outside of their expertise and remit, and less important than other health promotion activities such as smoking cessation. Professionals linked decisions on whether to advise physical activity to patients to their own physical activity levels and to subjective judgements of patient motivation. While some described ERS as a holistic alternative to medication, with potential social benefits, others expressed concerns regarding their limited reach and potential to exacerbate inequalities. Barriers to referral included geographic isolation and uncertainties about patient selection criteria, medico-legal responsibilities and a lack of feedback about patient progress.Conclusion:Clinicians’ concerns about expertise, priority setting and time constraints should be addressed to enhance physical activity promotion in primary care. Further research is needed to fully understand decision making relating to provision of physical activity advice and use of ERS.

Evaluation of Cwm Taf Health Board's knee-joint care programme a year from its completion: a professional-led dietetic and exercise intervention for obese patients with knee osteoarthritis

BackgroundThe National Institute for Health and Care Excellence recommends that weight loss and exercise are a core part of treatment for osteoarthritis. The delivery of these services within the National Health Service is by physiotherapists and dietitians in the secondary health-care setting. This feasibility study for obese patients with knee osteoarthritis was led by registered exercise professionals with the aim of assessing the potential for widespread use within the community. Methods81 patients met the inclusion criteria (body-mass index [BMI] >30 kg/m2 and radiological evidence of knee osteoarthritis) and were invited to participate through various routes (National Exercise Referral Scheme exclusion criteria were used). The intervention was a 16-week programme containing 1 h of exercise twice a week and 1 h a week of dietary advice. Primary outcome measures were Oxford knee score, quality of life (EQ-5D and EQ visual analogue scale [EQ-VAS]), and function (6-min walk test and 30 s sit to stand test). Outcome data were collected at week 16 and at 1 year after completion by the same exercise professionals. Student's t tests were used for statistical analysis. FindingsThe intervention started in January, 2013. 27 patients attended initial assessment and 18 finished the 16-week intervention. All 18 patients were white (nine men, mean age 59·7 years [SD 5·11], range 50–68), and had a starting BMI of 38·9 kg/m2 (SD 8·01). 14 patients completed 1-year follow-up (seven men, mean age 62·6 years [3·74], 53–69) and had a BMI of 33·34 kg/m2 (SD 5·08) at 1 year. At 1-year follow-up, significant changes were seen in the 30 s sit to stand test (mean change 3·6 repetitions, 95% CI 1·2 −5·96; p<0·0001) compared with baseline. Non-significant improvements were also seen in this time period for Oxford knee score (mean change 3·4, −4·97 to 11·7) and 6-min walk test (54·9 m, −51·4 to 161·3). InterpretationStatistically significant changes in 30 s sit to stand scores require investigation on a larger scale. Limitations include small sample size and lack of a control group. Sessions were run during working hours and no clear referral pathway was set up. Evening classes would allow working patients to participate, and incorporation of referral pathways within existing National Health Service structures would allow the programme to run at capacity. A larger study should advertise exit routes from the programme to enable long term success. FundingCwm Taf Health Board.

Psychosocial mediators of change in physical activity in the Welsh national exercise referral scheme: secondary analysis of a randomised controlled trial.

ObjectiveWhile an increasing number of randomised controlled trials report impacts of exercise referral schemes (ERS) on physical activity, few have investigated the mechanisms through which increases in physical activity are produced. This study examines whether a National Exercise Referral Scheme (NERS) in Wales is associated with improvements in autonomous motivation, self-efficacy and social support, and whether change in physical activity is mediated by change in these psychosocial processes.MethodsA pragmatic randomised controlled trial of NERS across 12 LHBs in Wales. Questionnaires measured demographic data and physical activity at baseline. Participants (N = 2160) with depression, anxiety or CHD risk factors were referred by health professionals and randomly assigned to control or intervention. At six months psychological process measures were collected by questionnaire. At 12 months physical activity was assessed by 7 Day PAR telephone interview. Regressions tested intervention effects on psychosocial variables, physical activity before and after adjusting for mediators and socio demographic patterning.ResultsSignificant intervention effects were found for autonomous motivation and social support for exercise at 6 months. No intervention effect was observed for self-efficacy. The data are consistent with a hypothesis of partial mediation of the intervention effect by autonomous motivation. Analysis of moderators showed significant improvements in relative autonomy in all subgroups. The greatest improvements in autonomous motivation were observed among patients who were least active at baseline.DiscussionThe present study offered key insights into psychosocial processes of change in an exercise referral scheme, with effects on physical activity mediated by autonomous motivation. Findings support the use of self-determination theory as a framework for ERS. Further research is required to explain socio-demographic patterning in responses to ERS, with changes in motivation occurring among all sub-groups of participants, though not always leading to higher adherence or behavioural change. This highlights the importance of socio-ecological approaches to developing and evaluating behaviour change interventions, which consider factors beyond the individual, including conditions in which improved motivation does or does not produce behavioural change.Trial register numberISRCTN47680448

A call to action: exercise as treatment for patients with mental illness.

Mental illness affects the lives of a significant number of Australians. In addition to pharmacological and psychological interventions, exercise has demonstrated benefits for people with mental illness including symptom reduction, improved cardiovascular risk profile and improved physical capacity. Unfortunately, evidence shows that clinician-delivered exercise advice is not routinely offered. This is despite patient acceptability for exercise. This article summarises the recent evidence supporting the prescription of exercise for people with mental illness and offers a model incorporating basic exercise prescription, and referral pathways for specialised advice. Current exercise prescription patterns for people with mental illness may not meet patient expectations; therefore, clinicians should consider exercise referral schemes to increase the accessibility of interventions for people with a mental illness.

Exercise-referral scheme to promote physical activity among hypertensive patients: design of a cluster randomized trial in the Primary Health Care Units of Mexico's Social Security System.

BackgroundAlthough the benefits of physical activity (PA) on to prevent and manage non-communicable diseases are well known, strategies to help increase the levels of PA among different populations are limited. Exercise-referral schemes have emerged as one effective approach to promote PA; however, there is uncertainty about the feasibility and effectiveness of these schemes in settings outside high-income countries. This study will examine the effectiveness of a scheme to refer hypertensive patients identified in Primary Health Care facilities (PHCU) of the Mexican social security institution to a group PA program offered in the same institution.Methods and designWe will describe the methods of a cluster randomized trial study designed to evaluate the effectiveness of an exercise referral scheme to increasing physical activity in hypertensive patients compared to a non-referral scheme. Four PHCU were selected for the study; the PHCU will take part as the unit of randomization and sedentary hypertensive patients as the unit of assessment. 2 PHCU of control group (GC) will provide information to hypertensive patients about physical activity benefits and ways to increase it safely. 2 PHCU of intervention group (IG) will refer patients to sports facilities at the same institution, to follow a group-based PA program developed to increase the PA levels with a designed based on the Transtheoretical Model and Social Cognitive Theory. To evaluate the effects of the intervention as well as short-term maintenance of the intervention’s effects, PA will be assessed at baseline, at 24 and 32 weeks of follow-up.The main outcome will be the difference before and after intervention in the percentage of participants meeting recommended levels of PA between and within intervention and control groups. PA will be measured through self-report and with objective measure by accelerometer.DiscussionThis study will allow us to evaluate a multidisciplinary effort to link the primary care and community-based areas of the same health care system. Our findings will provide important information about the feasibility and effectiveness of an exercise-referral scheme and will be useful for decision-making about the implementation of strategies for increasing PA among hypertensive and other clinical populations in Mexico and Latin America.Trial registrationClinicaltrials.gov Identifier: NCT01910935. Date of registration: 07/05/2013.

Assessing the Feasibility of Using Uniaxial Accelerometers With an Online Support Platform in the Delivery of a Community-Based Exercise Referral Scheme

Exercise referral schemes are established within community-based health care; however, they have been criticized for failing to evidence long-term behavior change relative to usual care. As such, recent reviews have called for refinement of their delivery with a focus on embedded strategies targeting client motivation. This research letter presents findings from an initial pilot trial conducted within Wales' National Exercise Referral Scheme (NERS), examining the feasibility of using validated physical activity monitoring devices and an accompanying online platform within standard scheme delivery. 30 individuals referred to generic or cardiovascular pathways were offered the system; of these 17 agreed to participate. Common reasons for declining were clustered into lack of technology literacy or access, condition severity, or fear of costs associated with losing the device. Analysis of follow-up interviews after 4 weeks of use indicated that while participants found the monitoring devices practical and informative, only a minority (n = 4) were using the system in full. Crucially, the system element most aligned with contemporary theories of motivation (the online portal) was not used as expected. In addition, feedback from exercise referral professionals indicated that there were demands for support from clients, which might be mitigated by more effective independent system use. Recommendations for larger scale trials using similar systems include consideration of targeted patient groups, equity of access, and providing adequate technological support that is currently beyond the capacity of the NERS system.

What do we mean by a flare of rheumatoid arthritis?

53% at age 16–24 to 16% at 65 plus. Similarly only 12% of women over 65 meet the recommended levels compared with 28–36% of younger women. Older people with musculoskeletal pain, commonly caused by OA and allied disorders, or less frequently by inflammatory arthropathies such as gout or RA, have reduced levels of everyday physical activity. The impact of chronic pain assessed by pain interference with daily activities increases throughout life into the oldest years. It is clear that regular physical activity improves both pain and quality of life, increases functional independence and reduces the risk of further chronic illness in those with joint pain, and should therefore be a target for intervention in older people with chronic pain. Developing interventions that increase rates of physical activity in older people with chronic musculoskeletal pain is challenging since they need to address pain-related factors such as fear of injury and fear of falling. There is also considerable patient uncertainty about the benefits of exercise, and interventions need to be implementable. While increasing exercise levels is a national and international priority, the mechanisms to achieve this remain unclear. Two recent systematic reviews and meta-analyses reported that exercise referral schemes in primary care were ineffective, but advice and counselling interventions were associated with small to medium short-term increases in selfreported physical activity. Walking is one way of increasing physical activity and has been described as near perfect exercise. Walking is already the most common form of exercise employed by older adults and has been identified as a priority for research by patients with joint pain. Interventions to promote walking have the potential to be successful since walking is perceived to be popular, familiar, convenient, social and free. Despite this there is a lack of effective interventions to promote walking for older people who have chronic pain. This presentation will summarize the current state of knowledge on behavioural interventions to increases walking in older people by addressing three main questions: What intervention should be delivered to promote walking in older people with chronic pain? How should the intervention be delivered? Who should deliver the intervention? Disclosure statement: The author has declared no conflicts of interest.

Effects of a standard provision versus an autonomy supportive exercise referral programme on physical activity, quality of life and well-being indicators: a cluster randomised controlled trial

BackgroundThe National Institute for Health and Clinical Excellence in the UK has recommended that the effectiveness of ongoing exercise referral schemes to promote physical activity should be examined in research trials. Recent empirical evidence in health care and physical activity promotion contexts provides a foundation for testing the feasibility and impact of a Self Determination Theory-based (SDT) exercise referral consultation.MethodsAn exploratory cluster randomised controlled trial comparing standard provision exercise referral with an exercise referral intervention grounded in Self Determination Theory. Individuals (N = 347) referred to an exercise referral scheme were recruited into the trial from 13 centres.Outcomes and processes of change measured at baseline, 3 and 6-months: Minutes of self-reported moderate or vigorous physical activity (PA) per week (primary outcome), health status, positive and negative indicators of emotional well-being, anxiety, depression, quality of life (QOL), vitality, and perceptions of autonomy support from the advisor, need satisfaction (3 and 6 months only), intentions to be active, and motivational regulations for exercise.Blood pressure and weight were assessed at baseline and 6 months.ResultsPerceptions of the autonomy support provided by the health and fitness advisor (HFA) did not differ by arm. Between group changes over the 6-months revealed significant differences for reported anxiety only. Within arm contrasts revealed significant improvements in anxiety and most of the Dartmouth CO-OP domains in the SDT arm at 6 months, which were not seen in the standard exercise referral group. A process model depicting hypothesized relationships between advisor autonomy support, need satisfaction and more autonomous motivation, enhanced well being and PA engagement at follow up was supported.ConclusionsSignificant gains in physical activity and improvements in quality of life and well-being outcomes emerged in both the standard provision exercise referral and the SDT-based intervention at programme end. At 6-months, observed between arm and within intervention arm differences for indicators of emotional health, and the results of the process model, were in line with SDT. The challenges in optimising recruitment and implementation of SDT-based training in the context of health and leisure services are discussed.Trial registrationThe trial is registered as Current Controlled trials ISRCTN07682833.

Exercise Referral in Germany

Primary care physicians in Germany are potentially in a pivotal position to provide physical activity counselling and exercise referral for their patients. The preventative prescription scheme dates back to the late 1970s. This scheme called “green prescription” (Grünes Rezept), however, could not be established as exercise referral scheme in primary care on a regular and systematic basis. After the German Medical Association (Bundesärztekammer), the German Association for Sports Medicine and Prevention (Deutsche Gesellschaft für Sportmedizin und Prävention) and the German Olympic Sports Federation (Deutscher Olympischer Sportbund) had developed the standardized national quality criteria of Physical Activity on Prescription in a joint effort, the German Medical Association has adopted them in 2011 and now recommends them to the Medical Associations of the Federal States for implementation. These national criteria establish a framework, but given the federal structure of Germany, schemes are not implemented in a uniform or centralized way. The federal states rather develop their own delivery methods according to local possibilities and needs. Exercise as a therapeutic means in the rehabilitation phase of a large number of chronic conditions as well as for people with disabilities is a legally established part of health care. The current legal and financial bases as well as the level of institutionalised support for the prescription of physical activity and exercise within health care are markedly different in the areas of prevention and therapy, respectively. While patients with chronic conditions are entitled to receive free exercise as a means of therapy (within certain limitations), no such “right” exists in the area of prevention. Exercise referrals rely on group offers with defined high standards in organised sports, making use of easily accessible sport clubs which are a traditional part of community life. Rigorous scientific evaluations are needed to provide guidance on how to further develop Germany´s exercise referral schemes.

Experiences in physical activity promotion in health care settings for primary prevention in the UK

In addition to the delivery of primary care services, recent changes to the NHS in the United Kingdom have placed increasing responsibility on GPs for the commissioning of the full range of health services from prevention through to clinical interventions and rehabilitation. Whilst historically there has always been an expectation that primary care professionals were ideally placed to provide support for prevention as well as treatment, their active engagement in the promotion of physical activity has remained largely superficial. With notable exceptions where individuals have a personal interest or commitment, the majority of health professionals tend to limit themselves to peremptory non-specific advice at best, or frequently don’t broach the subject at all. There are a number of reasons for this including increasing time pressures, a general lack of knowledge, limited evidence and concerns about litigation in the event of an adverse exercise induced event. However in the 1990s there was a surge of interest in the emerging “Exercise on Prescription” model where patients could be referred to community based exercise instructors for a structured “prescription” of exercise in community leisure centres. Despite the continuing popularity of the model there remain problems particularly in getting the active support of health professionals who generally cite the same barriers as previously identified. In an attempt to overcome some of these problems Wales established a national exercise referral scheme with an associated randomised controlled trial. The scheme evaluated well and had subsequently evolved with new developments including integration with secondary and tertiary care pathways, accredited training for exercise instructors and exit routes into alternative community based exercise opportunities.

Public health economics of body and mind: a health economist's perspective

BackgroundIf public health is the science and art of how society collectively aims to improve health, and reduce inequalities in health, then public health economics is the science and art of how we choose to do this with limited resources. The spectrum of public health activities is broad; for example, environmental policy, infectious disease control, individual behaviour change, and informing government legislation. I draw together key methodological considerations for the design, undertaking, and analysis of economic assessment alongside trials of public health interventions spanning environmental change and behaviour change relating to the body and mind. The discipline of health economics has grown up alongside a medical model of health. Many public health practitioners and health economists interested in public health are realising that emphasis is shifting from traditional behaviour-change interventions towards interventions that aim to change physical environments and social norms and that might need government legislation. This shift means that health economists need to approach the economic assessment of the broad spectrum of public health interventions in a more creative way. Quality-adjusted life-years may not fully capture diverse benefits of public health interventions but are useful for benchmarking the cost effectiveness of public health against clinical services. Health economists who have focussed on notions of efficiency need now to think more about equity, in view of public health goals of reducing inequalities in health. The aim is to convey to a public health science audience the challenges and opportunities facing health economists interested in public health today. MethodsI show these challenges and suggest solutions by drawing on recent published and ongoing trials of public health interventions with a health economics component. Changing the environment was investigated in the CHARISMA trial by improvement of heating and ventilation in homes of children with asthma. Changing individual physical behaviour was investigated by assessment of a national exercise referral scheme in the NERS trial. Changing individual mental behaviour was assessed by bringing mindfulness into the workplace in the Gwynedd trial. FindingsEmerging lessons include (1) the need to think about how evidence of cost effectiveness is going to be used by government and local commissioners of services, within what time horizon, and what the expected interplay may be between stakeholders; (2) mounting evidence that the government needs to focus on altering physical environments (eg, local planning laws, speed limits) and social environments (eg, school and workplace culture); and (3) a readiness to recognise where behaviour change has proved successful in the commercial sector, delivered in groups or online (eg, Slimming World). These three examples of economic analysis highlight thinking on design of economic assessment, power calculation issues relating to economic analysis, micro-costing techniques, and choice and range of outcome measures. InterpretationFaced with real public health challenges, we are beginning to learn how to design, undertake, and analyse economic assessments of public health interventions. We are learning how to provide clear evidence-based information to policy makers. Concrete recommendations to ensure funding streams for health economists, such as through the public health research programme, will help to support a methodological advancement in this field. FundingPublic Health Wales.

A retrospective analysis of an exercise-professional-led, community-based, dietary and exercise intervention for patients with knee osteoarthritis: a pilot study

BackgroundGuidance from the National Institute for Health and Care Excellence stipulates exercise and weight loss as core treatments for osteoarthritis. Typically, NHS physiotherapists and dietitians deliver these treatments within the secondary health-care setting. In view of increasing demands placed upon secondary health-care professionals, we undertook a novel pilot programme consisting of a community-based exercise and dietary intervention led by registered exercise professionals in obese patients with established knee osteoarthritis, to assess the efficacy and potentially widespread use of the intervention within the National Exercise Referral Scheme (NERS) in Wales. Methods80 white patients (body-mass index [BMI] ≥30 kg/m2) from Cwm Taf Health Board in Wales with radiological evidence of unilateral or bilateral knee osteoarthritis were invited (mean age 57·2 years [SD 7·4], BMI 38·5 kg/m2 [7·2]) from orthopaedic, rheumatology, and primary care settings in December, 2012. The exclusion criteria already in use by NERS were adhered to. Patients meeting the eligibility criteria were told by letter about the nature of the programme and were invited to attend an initial assessment. The 16-week pilot delivered dietary and exercise programmes in the community, with two 1-h sessions per week of aerobic and resistance exercise, 1 h per week of dietary education based on Public Health Wales' Foodwise for Life programme, and four practical cookery skills classes. Patients were separated into four groups, containing a maximum of eight patients per group. Primary outcome measures were Oxford knee score, quality of life (EQ-5D and EQ visual analogue scale [EQ-VAS]), and function (6-min walk test and 30 s sit–stand). Secondary measures were bodyweight, resting blood pressure, and resting heart rate. Outcome data were collected at week 16 of the pilot programme (June, 2013). Findings27 patients attended an initial assessment, four of whom declined to attend the programme and one of whom was excluded owing to a newly diagnosed medical disorder. 18 of the initial starting 22 patients completed the 16-week programme (nine men, mean age 59·7 years [SD 5·1], starting BMI 39·5 kg/m2 [8·0]). Seven of the 18 programme completers missed eight sessions or fewer. Statistically significant improvements between baseline and week 16 occurred in the Oxford knee score (mean 3·4, 95% CI 0·0–6·8; p=0·048), 6-min walk test (135·5 m, 92·0–179·0; p<0·0001), 30 s sit–stand (4·6 reps, 3·0–6·2; p<0·0001), EQ-VAS (15·5, 5·6–25·5; p=0·01), weight loss (−3·08 kg, −4·64 to −1·52; p=0·001), and systolic blood pressure (−22·4 mm Hg, −29·8 to −15·0) in those who completed the programme. Non-significant changes occurred in diastolic blood pressure (p=0·96), resting heart rate (p=0·11), and EQ-5D (p=0·11). No adverse events or side-effects were detected in the programme participants. InterpretationA community-based intervention led by exercise professionals for clinically obese patients with knee osteoarthritis could be a useful therapeutic resource for health professionals. Significant improvements in pain scores, function, and quality of life occurred in those who completed the programme. However, there are limitations in the study design because of the absence of a comparator group, the small sample size, and the retrospective nature of the study. The recruitment process used was suboptimal, and further investigation into the optimum referral pathway into such a programme is suggested. Furthermore, the long-term effect of this programme on participants needs detailed ongoing assessment. The programme costs were calculated at £1222 per patient. This substantial expenditure could be reduced to £687 per patient if the programme ran at maximum capacity (eight patients per session). FundingCwm Taf Health Board.