‘If physical activity was a pill, doctors could well be prescribing it to everyone’ by Coral Hanson
(31 May 2017)
(Physical Activity SIG ECR and PhD candidate)
The health benefits of being physically active are well-known. For example, being active leads to a reduction in the risk of developing heart disease (Sofi et al., 2008) or dying prematurely (Nocon et al., 2008) of heart disease, a reduction in the chance of developing bowel cancer (Harriss et al., 2009), breast cancer (Schottenfeld et al., 2013), diabetes (Jeon et al., 2007) and depression (Mammen and Faulkner, 2013). If exercise was a pill, doctors could well be prescribing it to everyone.
Unfortunately, as yet, no-one has developed a drug that will reproduce all the health benefits of being active, or one that will make us want to exercise more. Health professionals are therefore faced with a dilemma in knowing the best way to ‘prescribe’ physical activity for their patients.
What should such a prescription look like? For an adult, 150 minutes of moderate or 75 minutes of vigorous physical activity a week, or a combination of the two (Department of Health, 2011) (each minute of vigorous activity counts as two minutes of moderate activity). In England in 2015/16 61% of adults were classified as active (achieving the guidelines above), 13% as fairly active (doing between 30 and 149 minutes) and 26% were classed as inactive (doing less than 30 minutes of activity a week) (Sport England, 2017).
If you are reading this thinking, ‘hmmm, actually that’s not too bad’, bear in mind that these figures were self-reported and research shows that they are likely to be an overestimation (Chaudhury et al., 2010) of the percentage of the population who really do enough. In fact, in the UK it is estimated that physical inactivity directly contributes to one in ten premature deaths (Lee et al., 2012), and in 2013 it was estimated that the direct health cost was £1.3 billion (Ding et al., 2016).
So how can health professionals ‘prescribe’ physical activity? One potential solution is exercise referral schemes (ERS), which typically allow for referral of inactive patients with long-term health conditions to a leisure provider for a supervised exercise programme of between 12 and 24 weeks. These schemes were the subject of a symposium hosted by the Physical Activity Special Interest Group of the Wolfson Research Institute for Health and Wellbeing, on 14th October 2016. They are also the focus of my PhD thesis and now the focus of my post-doctoral research. In addition, between 1995-2016 I developed and managed the Northumberland ERS, overseeing thousands of referrals. This is a subject very close to my heart and one that has resulted in my transition from a leisure professional to an academic researcher.
ERS have existed since the 1990s and are widespread throughout the UK, but the jury is out about effectiveness. In 2006, National Institute for Health and Care Excellence issued guidance (National Institute for Health and Clinical Excellence, 2006) stating that there was insufficient evidence to justify commissioning schemes unless they were part of a research study. As a scheme provider, this was both a curse (having no concept of how to integrate research into practice and, as importantly, no money to do it) and a mixed blessing (it led to me undertaking a PhD, but while working full time). Having since undertaken six years of research, I have recently been reflecting on what has changed for ERS.
On the one hand, it seems not a lot. In 2014, Public Health England criticised the evidence base for ERS (Public Health England, 2014), owing to the sparse use of randomised controlled trials (RCTs) and what is considered to be substandard evaluation. Systematic reviews (Campbell et al., 2015, Pavey et al., 2011) still question long-term effectiveness and cost-effectiveness. Consequently, in updated guidance in 2014, (National Institute for Health and Care Excellence, 2014) the National Institute for Health and Care Excellence advised a cautious approach to commissioning.
On the other hand, there has been a recognition that using only RCT-based evidence may not be the most appropriate way to assess ERS. In Wales, a national ERS was developed, with both an outcome RCT (Murphy et al., 2012) and a process evaluation (Moore et al., 2013) being undertaken. This approach has attempted to produce ‘gold standard’ evidence, while also including an assessment of implementation and an exploration of stakeholder (strategic planner, referring health professional, provider and participant) experiences. The results of the RCT imply that the scheme was effective in changing physical activity behaviour for those referred for coronary heart disease risk only (providing the potential for more targeted delivering of the existing scheme). The process evaluation provided important information about what works (and does not work) in terms of delivery - and why - allowing for future developments and the trialing of different approaches.
There are an increasing number of research groups / PhD students who have undertaken, or are currently undertaking, mixed method evaluations of existing schemes (myself included). While not recognised as ‘gold standard’, these are providing valuable information about which subgroups of the population ERS are more likely to be successful for (for example, those who are older) (Hanson et al., 2013), what ‘active ingredients’ influence success (for example, staff and peer support) (Morgan et al., 2016), and how behaviour change techniques are implemented within such schemes (not very well) (Beck et al., 2016). Our symposium provided an important opportunity for ERS researchers nationwide to come together and discuss these very real developments – and notably from a very much needed multidisciplinary perspective. As well as my own presentation, we were delighted to welcome Paula Watson and her team from Liverpool, Kim Buxton from the British Heart Foundation National Centre, Gemma Hawkins representing the Welsh National Scheme, Mike Kelly (South Tyneside), Steven Mann from UK Active, Hannah Henderson (Lincoln) and our own Ben Rigby and Nick Walton from Durham, both starting out on their respective PhD journeys. With a room full of open minded psychologists, physiologists and social scientists, the potential for interdisciplinary research to really move this field forward was evident - and very exciting.
Clearly research findings need to be widely disseminated to both health and leisure professionals, so that schemes can be (re)designed to be better targeted and delivered. The next step in this process should be interdisciplinary evaluation of what effect any changes to practice make, followed by new RCTs where practice is found to be promising. This requires long-term partnerships between provider organisations and university researchers, not to mention a continuation of funding until successful practice is identified and proven.
Is there a real potential for ERS to effectively increase physical activity for those who are referred? We believe there is, but only if they are sufficiently targeted and well delivered. The leisure industry is finally waking up to the need to produce evidence (education is most definitely required) and there are moves to create a national repository for ERS data (UK Active). Furthermore there are researchers who are committed to working with commissioners and providers to guide intervention design and help produce future evidence. ERS are not an easy ‘physical activity pill’ but they do have the potential to contribute to a more active nation, if we researchers can work together – and in the right way – across our respective disciplines.
The Physical Activity SIG would like to thank the WRI for funding our symposium.
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