National Exercise Referral Scheme Research Articles

AN EXERCISE PROFESSIONAL LED, COMMUNITY BASED, DIETARY AND EXERCISE PROGRAMME FOR KNEE OSTEOARTHRITIS

NICE guidance stipulates exercise and weight loss as ‘Core’ treatments for Osteoarthritis (OA). Typically, NHS physiotherapists and dieticians deliver these treatments within the secondary health care setting. Given increasing demands...

Mixed-method process evaluation of the Welsh National Exercise Referral Scheme

Purpose Primary-care referral to community-based exercise specialists (exercise referral) is common in the UK despite limited evidence of effectiveness. A recent pragmatic randomised trial of the Welsh National Exercise Referral Scheme (NERS), demonstrated promising impacts upon physical activity and mental health. This paper presents a mixed-method process evaluation exploring how outcomes were achieved.

Use of health economics and programme budgeting and marginal analysis at a national level to prioritise public health improvement programmes in Wales

BackgroundWales spends more than £60 million per year on national public health improvement programmes, which currently are largely without a systematic evidence base or rationale. Economic evidence for public health programmes is sparse. However, it is essential to help inform policy and implementation. Owen and colleagues (2010) synthesised the evidence of 200 base-case cost-effectiveness estimates of evidence underpinning National Institute for Health and Clinical Excellence (NICE) public health guidance from 2006–10, because no comprehensive list of estimates was previously available. MethodsWe describe a national All Wales programme budgeting and marginal analysis (PBMA) analysis lead by Public Health Wales. We build on a mapping exercise of current Welsh Government-funded health improvement programmes, primarily delivered by the public sector, undertaken by Prof Sir Mansel Aylward. PBMA analysis offers a transparent and systematic way to examine policy goals, key stakeholders, and evidence of effectiveness, cost-effectiveness, and reach to disadvantaged groups. We discuss the practical challenge of promoting consultative buy-in by Directors of Public Health and their teams at the seven health boards across Wales, while managing necessary budgetary control and strategic planning at a national level. FindingsThe 31 programmes reviewed span infant and childhood programmes such as Designed to Smile (a programme to improve the dental health of infants and children in Wales), programmes for adolescents such as peer-led smoking cessation programmes (ASSIST), adulthood programmes such as smoking cessation services for example helplines and brief interventions, and the National Breastfeeding Programme, to programmes for older adults such as the National Exercise Referral Scheme. There is disparity between the funding of these programmes and the availability of clinical and cost-effectiveness data for each programme. We also noted that most programmes are weighted more towards the youth of Wales with a higher number of programmes aimed at pregnant mothers, infants, children, and adolescents. InterpretationThis PBMA exercise at a national All Wales level will map out current spending on health improvement and the full range of agencies and professionals currently delivering health improvement programmes, spanning the NHS, local government, schools, and the third sector. We will relate this budget to evidence of clinical and cost-effectiveness, the extent to which programmes match with stated Welsh Government health policy objectives and key themes, and the current and potential effect on reducing health inequalities. This search will also help to identify potential new opportunities for introduction or implementation through existing services of evidence-based health improvement programmes or interventions not currently funded or delivered in Wales. This is rational reinvestment in action. FundingNone.

Facilitating adherence to physical activity: exercise professionals' experiences of the National Exercise Referral Scheme in Wales. a qualitative study

BackgroundAlthough implementers' experiences of exercise referral schemes (ERS) may provide valuable insights into how their reach and effectiveness might be improved, most qualitative research has included only views of patients. This paper explores exercise professionals' experiences of engaging diverse clinical populations in an ERS, and emergence of local practices to support uptake and adherence in the National Exercise Referral Scheme (NERS) in Wales.MethodsThirty-eight exercise professionals involved in the delivery of NERS in 12 local health board (LHB) areas in Wales took part in a semi-structured telephone interview. Thematic analysis was conducted.ResultsProfessionals' accounts offered insights into how perceived needs and responses to NERS varied by patient characteristics. Adherence was described as more likely where the patient sought referral from a health professional rather than being advised to attend. Hence, professionals sometimes described a need for the referral process to identify patients for whom change was already internally motivated. In addition, mental health patients were seen as facing additional barriers, such as increased anxieties about the exercise environment. Professionals described their role as involving helping patients to overcome anxieties about the exercise environment, whilst providing education and interpersonal support to assist patients' confidence and motivation. However, some concerns were raised regarding the levels of support that the professional should offer whilst avoiding dependence. Patient-only group activities were described as supporting adherence by creating an empathic environment, social support and modelling. Furthermore, effectively fostering social support networks was identified as a key mechanism for reducing dependence and maintaining changes in the longer term.ConclusionsWhether ERS should identify motivated patients, or incorporate activities to support internalisation of motivation amongst less motivated patients deserves attention. As well as providing the knowledge to advise patients on how to exercise safely given their conditions, professionals' training should focus on providing the skills to meet the interpersonal support needs of patients, particularly where ERS are used as a means of improving mental health outcomes. The effectiveness of emerging activities, such as post-scheme maintenance classes, in fostering long-term social networks supportive of physical activity deserve attention.Trial registrationCurrent Controlled Trials: ISRCTN47680448

Integration of Motivational Interviewing into Practice in the National Exercise Referral Scheme in Wales: A Mixed Methods Study

Though motivational interviewing (MI) has demonstrated efficacy in a range of behaviour change settings, effectiveness will require successful integration into everyday practice. This study examines implementers' views on delivering MI within an exercise referral scheme and consistency of consultations with MI before and after a 2-day workshop. Semi-structured interviews were conducted with 27 exercise professionals and 10 area coordinators delivering the Welsh National Exercise Referral Scheme (NERS), and the MI trainer. Eleven professionals provided consultation recordings before and 6-months after training, coded for fidelity using the Behaviour Change Counselling Index. The workshop was well received by most, triggering increased recognition of potential motivational roles of consultations. However, some cited difficulties combining MI with structured data gathering activities, whilst a minority rejected MI, seeing current practice as effective, or MI as unnecessary because patients were ready to change. Although limited aggregate improvement in practice was observed, substantial improvements were observed in some individuals. Comments on the need for further practice or training were widespread. Efforts to implement MI should ensure that training and structures to provide monitoring and feedback are in place and that activities incorporated within consultations are compatible with MI delivery.

A pragmatic randomised controlled trial of the Welsh National Exercise Referral Scheme: protocol for trial and integrated economic and process evaluation

BackgroundThe benefits to health of a physically active lifestyle are well established and there is evidence that a sedentary lifestyle plays a significant role in the onset and progression of chronic disease. Despite a recognised need for effective public health interventions encouraging sedentary people with a medical condition to become more active, there are few rigorous evaluations of their effectiveness. Following NICE guidance, the Welsh national exercise referral scheme was implemented within the context of a pragmatic randomised controlled trial.Methods/DesignThe randomised controlled trial, with nested economic and process evaluations, recruited 2,104 inactive men and women aged 16+ with coronary heart disease (CHD) risk factors and/or mild to moderate depression, anxiety or stress. Participants were recruited from 12 local health boards in Wales and referred directly by health professionals working in a range of health care settings. Consenting participants were randomised to either a 16 week tailored exercise programme run by qualified exercise professionals at community sports centres (intervention), or received an information booklet on physical activity (control). A range of validated measures assessing physical activity, mental health, psycho-social processes and health economics were administered at 6 and 12 months, with the primary 12 month outcome measure being 7 day Physical Activity Recall. The process evaluation explored factors determining the effectiveness or otherwise of the scheme, whilst the economic evaluation determined the relative cost-effectiveness of the scheme in terms of public spending.DiscussionEvaluation of such a large scale national public health intervention presents methodological challenges in terms of trial design and implementation. This study was facilitated by early collaboration with social research and policy colleagues to develop a rigorous design which included an innovative approach to patient referral and trial recruitment, a comprehensive process evaluation examining intervention delivery and an integrated economic evaluation. This will allow a unique insight into the feasibility, effectiveness and cost effectiveness of a national exercise referral scheme for participants with CHD risk factors or mild to moderate anxiety, depression, or stress and provides a potential model for future policy evaluations.Trial registrationCurrent Controlled Trials ISRCTN47680448

“The wise, for cure, on exercise depend”: physical activity interventions in primary care in Wales

Physical inactivity is an important public health problem, which could be addressed by health promotion initiatives in primary care. The interventions most widely available to primary care clinicians are advice/counselling...