Matti Leijon

Physical activity on prescription in primary health care: a follow-up of physical activity level and quality of life.

To examine whether physical activity on prescription in routine primary care patients would influence physical activity level and quality of life 6 months later. In 2001–2003, 13 Swedish primary health care units took part in an uncontrolled clinical study. If a patient in primary health care needed physical activity preventively or for treatment of a disease and patient‐centered motivational counseling found physical activity to be suitable, individualized physical activity could be prescribed. Patients (n=481) of both sexes and all ages [75% women, mean age 50 (12–81)] participated in the study. Self‐reported physical activity, readiness to change to a more physically active lifestyle and quality‐of‐life data were collected through questionnaires. The follow‐up rate was 62% at 6 months. Intention‐to‐treat analysis showed a significant increase (P<0.01) in self‐reported physical activity level, the stages of action and maintenance of physical activity as well as quality of life. Physical activity level, stages of change and quality of life increased analogically, indicating that physical activity on prescription may be suitable as a conventional treatment in an ordinary primary health care setting to promote a more physically active lifestyle.

Does a physical activity referral scheme improve the physical activity among routine primary health care patients

Physical activity referral (PAR) schemes or concepts occur in varying forms. Because few physical activity intervention studies have been carried out in routine health care settings, it is difficult to translate research findings into daily practice. The aim of this study was to analyze the effectiveness of a PAR scheme implemented in routine primary health care. The study did not include a control group and was based on the ordinary staffs work efforts and follow‐up measures. During a 2‐year period, 6300 PARs were issued. Effectiveness was measured by an increase in self‐reported physical activity. Half of the patients reached reported increased physical activity both at 3 months (49%) and at 12 months (52%). The proportion of inactive patients decreased from 33% at baseline to 17% at 3 months and 20% at 12 months. The proportion of patients who were physically active on a regular basis increased from 22% at baseline to 33% at 3 months and 32% at 12 months. Neither the patients age nor the profession of the prescriber was associated with differences in effectiveness. The patients activity level at baseline, the type of physical activity as well as the reason for the prescription were associated with increased physical activity.

Physical activity referrals in Swedish primary health care - prescriber and patient characteristics, reasons for prescriptions, and prescribed activities.

BackgroundOver the past decade, practitioners in primary health care (PHC) settings in many countries have issued written prescriptions to patients to promote increased physical activity or exercise. The aim of this study is to describe and analyse a comprehensive physical activity referral (PAR) scheme implemented in a routine PHC setting in Östergötland County. The study examines characteristics of the PARs recipients and referral practitioners, identifies reasons why practitioners opted to use PARs with their clients, and discusses prescribed activities and prescriptions in relation to PHC registries.MethodsProspective prescription data were obtained for 90% of the primary health care centres in Östergötland County, Sweden, in 2004 and 2005. The study population consisted of patients who were issued PARs after they were deemed likely to benefit from increased physical activity, as assessed by PHC staff.ResultsDuring the two-year period, a total of 6,300 patients received PARs. Two-thirds of the patients were female and half of the patients were 45–64 years. Half of the patients (50.8%) who received PARs were recommended a home-based activity, such as walking. One third (33%) of the patients issued PARs were totally inactive, reporting no days of physical activity that lasted for 30 minutes, and 29% stated that they reached this level 1–2 days per week.The number of PARs prescribed per year in relation to the number of unique individuals that visited primary health care during one year was 1.4% in 2004 and 1.2% in 2005. Two-thirds of the combined prescriptions were issued by physicians (38%) and nurses (31%). Physiotherapists and behavioural scientists issued the highest relative number of prescriptions. The most common reasons for issuing PARs were musculoskeletal disorders (39.1%) and overweight (35.4%), followed by high blood pressure (23.3%) and diabetes (23.2%).ConclusionÖstergötland Countys PAR scheme reached a relatively high proportion of physically inactive people visiting local PHC centres for other health reasons. PAR-related statistics, including PAR-rates by individual PHC centres and PAR- rates per health professional category, show differences in prescribing activities, both by patient categories, and by prescribing professionals.

Who is not adhering to physical activity referrals, and why?

Objective. To analyse patients’ self-reported reasons for not adhering to physical activity referrals (PARs). Design and setting. Data on 1358 patients who did not adhere to PARs were collected at 38 primary health care (PHC) centres in Sweden. Intervention. PHC providers issued formal physical activity prescriptions for home-based activities or referrals for facility-based activities. Subjects. Ordinary PHC patients whom regular staff believed would benefit from increased physical activity. Main outcome measure: Reasons for non-adherence to PARs: “sickness”, “pain”, “low motivation”, “no time”, “economic factors”, and “other”. Results. Sickness and pain were the most common motives for non-adherence among older patients. The youngest patients blamed economic factors and lack of time more frequently than those in the oldest age group. Economic factors was a more common reason for non-adherence among those referred for facility-based activities compared with those prescribed home-based activities. Low motivation was a more frequent cause of non-adherence among those prescribed home-based activities compared with those referred for facility-based activities. Furthermore, lack of time was a more common reason for non-adherence among patients issued with PARs due to high blood pressure than other patients, while low motivation was a more common reason among patients issued with PARs because of a BMI of > 25. Conclusion. The reasons for non-adherence differ between patients prescribed home-based activities and referred for facility-based activities, as well as between patients with different specific characteristics. The information obtained may be valuable not only for the professionals working in PHC, but also for those who work to develop PARs for use in different contexts.

Computerized lifestyle intervention in routine primary health care: Evaluation of usage on provider and responder levels

OBJECTIVE The aim of this study was to evaluate the use of a computerized concept for lifestyle intervention in routine primary health care (PHC). METHODS Nine PHC units were equipped with computers providing a lifestyle test and tailored printed advice regarding alcohol consumption and physical activity. Patients were referred by staff, and performed the test anonymously. Data were collected over a period of 1 year. RESULTS During the study period 3,065 tests were completed, representing 5.7% of the individuals visiting the PHC units during the period. There were great differences between the units in the number of tests performed and in the proportion of patients referred. One-fifth of the respondents scored for hazardous alcohol consumption, and one-fourth reported low levels of physical activity. The majority of respondents found the test easy to perform, and a majority of those referred to the test found referral positive. CONCLUSION The computerized test can be used for screening and intervention regarding lifestyle behaviours in PHC. Responders are positive to the test and to referral. PRACTICE IMPLICATIONS A more widespread implementation of computerized lifestyle tests could be a beneficial complement to face-to-face interventions in PHC.

Referral to an electronic screening and brief alcohol intervention in primary health care in Sweden: impact of staff referral to the computer

The aim of this paper was to evaluate whether primary health care staffs referral of patients to perform an electronic screening and brief intervention (e-SBI) for alcohol use had a greater impact on change in alcohol consumption after 3 month, compared to patients who performed the test on their own initiative. Staff-referred responders reported reduced weekly alcohol consumption with an average decrease of 8.4 grams. In contrast, self-referred responders reported an average increase in weekly alcohol consumption of 2.4 grams. Staff-referred responders reported a 49% reduction of average number of heavy episodic drinking (HED) occasions per month. The corresponding reduction for self-referred responders was 62%. The differences between staff- and self-referred patient groups in the number who moved from risky drinking to nonrisky drinking at the followup were not statistically significant. Our results indicate that standalone computers with touchscreens that provide e-SBIs for risky drinking have the same effect on drinking behaviour in both staff-referred patients and self-referred patients.

Cross-cultural validation of a simple self-report instrument of physical activity in immigrants from the Middle East and native Swedes

Aim: To investigate cross-cultural validity of a simple self-report instrument of physical activity intended to be used in Swedish health care. Methods: A validation study performed in 599 Iraqis (58% men) and 553 Swedes (53% men) aged 30–75 years living in the city of Malmö, Sweden. The self-report instrument by the Swedish National Board of Health and Welfare was compared to corresponding measures assessed from accelerometry as reference. Results: The agreement between the methods in assessing the participants as sufficiently/insufficiently physically active (cut-point 150 min/week) was 65% in the Iraqis and 52% in the Swedes (p<0.001). The proportion disagreement where the self-reported physical activity was sufficient but insufficient according to the accelerometry was 26% and 45% in Iraqis and Swedes, respectively. Physical activity time (min/week) was overestimated by self-report compared to accelerometry by 71% in the Iraqis and 115% in the Swedes (p<0.001). The smallest and largest overestimation was seen in Iraqi (57%) and Swedish (139%) women, respectively. The deviation of the self-report instrument compared to accelerometry was related to the physical activity level, as the overestimation mainly occurred at lower physical activity. Conclusions: The self-report instrument proposed by the Swedish National Board of Health and Welfare may overestimate the proportion sufficiently physically active, but to an extent depending on cultural background and gender.

Improvement of Physical Activity by a Kiosk-based Electronic Screening and Brief Intervention in Routine Primary Health Care: Patient-Initiated Versus Staff-Referred

Background Interactive behavior change technology (eg, computer programs, Internet websites, and mobile phones) may facilitate the implementation of lifestyle behavior interventions in routine primary health care. Effective, fully automated solutions not involving primary health care staff may offer low-cost support for behavior change. Objectives We explored the effectiveness of an electronic screening and brief intervention (e-SBI) deployed through a stand-alone information kiosk for promoting physical activity among sedentary patients in routine primary health care. We further tested whether its effectiveness differed between patients performing the e-SBI on their own initiative and those referred to it by primary health care staff. Methods The e-SBI screens for the physical activity level, motivation to change, attitudes toward performing the test, and physical characteristics and provides tailored feedback supporting behavior change. A total of 7863 patients performed the e-SBI from 2007 through 2009 in routine primary health care in Östergötland County, Sweden. Of these, 2509 were considered not sufficiently physically active, and 311 of these 2509 patients agreed to participate in an optional 3-month follow-up. These 311 patients were included in the analysis and were further divided into two groups based on whether the e-SBI was performed on the patient´s own initiative (informed by posters in the waiting room) or if the patient was referred to it by staff. A physical activity score representing the number of days being physically active was compared between baseline e-SBI and the 3-month follow-up. Based on physical activity recommendations, a score of 5 was considered the cutoff for being sufficiently physically active. Results In all, 137 of 311 patients (44%) were sufficiently physically active at the 3-month follow-up. The proportion becoming sufficiently physically active was 16/55 (29%), 40/101 (40%), and 81/155 (52%) for patients with a physical activity score at baseline of 0, 1 to 2, and 3 to 4, respectively. The patient-initiated group and staff-referred group had similar mean physical activity scores at baseline (2.1, 95% confidence interval [CI] 1.8-2.3, versus 2.3, 95% CI 2.1-2.5) and at follow-up, (4.1, 95% CI 3.4-4.7, vs 4.2, 95% CI 3.7-4.8). Conclusions Among the sedentary patients in primary health care who participated in the follow-up, the e-SBI appeared effective at promoting short-term improvement of physical activity for about half of them. The results were similar when the e-SBI was patient-initiated or staff-referred. The e-SBI may be a low-cost complement to lifestyle behavior interventions in routine primary health care and could work as a stand-alone technique not requiring the involvment of primary health care staff.

The longitudinal exercise trend among older Swedes aged 53-84 years - a 16-year follow-up study.

BackgroundMany older adults are physically inactive and inactivity increases with age. This knowledge comes from cross-sectional studies. Cross-sectional studies may miss important trajectories within the older adults as a result of retirements, and poor health impact of promotional efforts. The aim of this study was to analyse, longitudinally, the annual effects of age group and birth cohort on self-reported regular exercise in the Swedish population aged 53–84 years during a 16-year period, for each sex separately.MethodsA random sample of non-institutionalized persons was interviewed three times from 1988 to 2004 by professional interviewers. In addition to three time-related variables – year of interview, age at the time of the interview, and year of birth – we included the following explanatory variables in the analyses: educational level, body mass index, smoking, and self-reported health status. The data were analysed by a mixed model with a random intercept.ResultsThe total prevalence of self-reported regular exercise increased between 1988/89 and 2004/05 among both men and women, from 27.1 to 43.1% and from 21.1 to 41.1%, respectively. There was a mean annual change in all age-groups in exercise of between 0.76 and 1.24% among men and between 0.86 and 1.38% among women. Low prevalence of self-reported regular exercise was associated with low educational level, obesity, smoking, and poor self-reported health, although those with poor self-reported health the greatest increase of physical activity.ConclusionsThere was a steady, albeit inadequate, increase in self-reported regular exercise in older adults between 1988 and 2004. Physical activity promotion in older adults should be of high priority for both primary and secondary prevention of diseases, especially among groups with known risk factors for low levels of exercise.

Study protocol: a multi-professional team intervention of physical activity referrals in primary care patients with cardiovascular risk factors—the Dalby lifestyle intervention cohort (DALICO) study

BackgroundThe present study protocol describes the trial design of a primary care intervention cohort study, which examines whether an extended, multi-professional physical activity referral (PAR) intervention is more effective in enhancing and maintaining self-reported physical activity than physical activity prescription in usual care. The study targets patients with newly diagnosed hypertension and/or type 2 diabetes. Secondary outcomes include: need of pharmacological therapy; blood pressure/plasma glucose; physical fitness and anthropometric variables; mental health; health related quality of life; and cost-effectiveness.Methods/DesignThe study is designed as a long-term intervention. Three primary care centres are involved in the study, each constituting one of three treatment groups: 1) Intervention group (IG): multi-professional team intervention with PAR, 2) Control group A (CA): physical activity prescription in usual care and 3) Control group B: treatment as usual (retrospective data collection). The intervention is based on self-determination theory and follows the principles of motivational interviewing. The primary outcome, physical activity, is measured with the International Physical Activity Questionnaire (IPAQ) and expressed as metabolic equivalent of task (MET)-minutes per week. Physical fitness is estimated with the 6-minute walk test in IG only. Variables such as health behaviours; health-related quality of life; motivation to change; mental health; demographics and socioeconomic characteristics are assessed with an electronic study questionnaire that submits all data to a patient database, which automatically provides feed-back to the health-care providers on the patients’ health status. Cost-effectiveness of the intervention is evaluated continuously and the intermediate outcomes of the intervention are extrapolated by economic modelling.DiscussionsBy helping patients to overcome practical, social and cultural obstacles and increase their internal motivation for physical activity we aim to improve their physical health in a long-term perspective. The targeted patients belong to a patient category that is supposed to benefit from increased physical activity in terms of improved physiological values, mental status and quality of life, decreased risk of complications and maybe a decreased need of medication.