I am of course at the age, 62, where lifestyle choices begin to have more than temporary consequences, and my own response has been to choose to be sensible over diet and weight control, but above all to keep "stoking the fires" of competitive endurance running as long as I possibly can.
Clearly not everyone has felt able to make the same choices. In nearly all the offroad races I have completed in the past 13 months, I have been one of a handful, at most, of men my age. I am not the quickest or most experienced trail and ultra runner, but in fields of 150-300 runners totally, I remain unbeaten in my age group at distances above 50 km.
This does not reflect my ability, but more the lack of competition!
In my opinion many factors, not all of them physical, lead people into giving up competitive endurance sport as they get older. Social and psychological support or any form of systemic encouragement is virtually non-existent. You become an outlier at just the time in your life when the benefits of exercise on so many physical and mental health markers should make you part of a mainstream that seeks to guide society and make healthcare cheaper for everyone.
As part of an Open Univeristy Open BSc that I worked on part-time from 2009 to 2014, I completed a final year course on Public Health in my final year. Fortunately the marks I obtained on this unit contributed significantly to my award of 1st class honours for the degree as a whole.
As part of the public health unit, a long essay / report was required as 50% of the marks, and in this we were required to design and critically evaluate a public health intervention in our own locality. I think enough time has passed now to allow me to publish this online, as my chosen topic was exercise adherence in people who might be likely to be prescribed an exercise routine by an NHS Doctor, ie. very relevant to the topic. I don't claim my own work to be a masterpiece, but there are references to supporting papers in the academic journals, and I have not seen anything similar proposed in the intervening 3 years, despite the fact that I think it would work.
Here is the complete text and references, including the assignment brief:
You are required to develop a proposal for a public health intervention, using your chosen planning model.
PART 1 Identify what type of public health intervention you plan to focus on and investigate the evidence base for your chosen intervention. Cite relevant sources, justify your particular focus and produce a detailed plan for your intervention.
PART 2 Outline how you would implement and evaluate your plan, clarifying target population for the intervention, timescales and selected methods.
PART 3 Assess the policy implications of your intervention and its relevance to policies and strategies at national and local level.
PART 4 Critically reflect on your work, identifying what you consider to be its main strengths and weaknesses.
Introduction
"Lack of physical activity is the fourth most important risk factor worldwide for chronic, non communicable diseases, after tobacco use, raised blood pressure, and hyperglycaemia. (Scholes & Mindell, 2012, p1)
"Age 50 marks a point in middle age at which the benefits of regular physical activity can be most relevant in avoiding, minimising, and/or reversing many of the physical, psychological, and social problems which often accompany advancing age." (WHO, 2002, p112)
Public health policymakers throughout the developed world have accepted the implications of the consensus view quoted above and have sought to create interventions that encourage a "healthy lifestyle" profile amongst citizens. In the UK there have been several initiatives, media campaigns and interventions, at both a national and local level, directed towards increasing physical activity levels, alongside those aimed at other risk factors such as smoking, diet and weight management. One particular intervention type has been applied to particular "at risk" groups, usually based on prior health screening at a GP clinic, and this is the "Exercise on Referral Scheme" (ERS), whereby patients are referred for a set number of sessions to a personal trainer, usually at a gym or leisure centre. The aim is to "train" the individual into a higher level of physical activity and measure the results in terms of key cardiovascular, blood chemistry and body mass indicators. Recent evidence has suggested that these interventions have been less successful than anticipated, with adherence to schemes by subjects after an initial period generally disappointing. Their long term benefit in initiating behaviour and lifestyle change has been called into question. The following planned pilot intervention, "Whitchurch gets Walking" (WGW), attempts to address some of the shortcomings of current ERS in a rural setting in North Buckinghamshire where formal exercise infrastructure is not immediately available. It changes the emphasis to psychological support using sports psychologists rather than technical / medical monitoring done by medical staff and exercise professionals. The principal goals of the intervention are centred on adherence to behaviour and lifestyle change rather than meeting pre-determined standards of physical fitness and body mass index. It also employs a social networking approach and virtual tools to monitor progress, with empowerment of the subject in their own lifestyle change becoming a key theme.
The proposed intervention follows the Nutbeam & Harris 5 phase model which integrates theory and evidence based practise into the planning, implementation and evaluation of public health interventions. (Sidell & Douglas, 2012, p256)
Part 1 - Problem identification, intervention rationale and solution planning (Phases 1 and 2)
According to the latest Health Survey for England,
"Adults should be encouraged to undertake each week at least 150 minutes of moderate activity, in bouts of 10 minutes or longer, or 75 minutes of vigorous activity or a combination of both." (Scholes & Mindell, 2012, p2)
The latest evidence suggests that conventional ERS are failing to either achieve these modest objectives with at risk patients or to foster an acceptable adherence rate on schemes which may lead to long term behaviour change. An evaluation of the National ERS in Wales in 2010 found that 45% of patients dropped out within 4 weeks, and in some areas as little as 11% completed a 16 week programme. (Murphy et al., 2010, p13) In a review of the ERS in Northumberland in 2009-10, even those who completed the scheme only managed to increase their self reported mean weekly physical activity from an average of 52 minutes to 81 minutes, just 54% of the recommended minimum of 150 minutes. (Hanson et al, 2013, p7) A systematic review and meta analysis of studies on ERS in England in 2011 found that,
"..there remains very limited support for the potential role of exercise referral schemes on increasing physical activity and consequently improving public health." (Pavey et al., 2011, p5)
With supervision of such schemes largely in the hands of referring GP's and the exercise specialists themselves, it is at least plausible that not enough attention has hitherto been paid to intrinsic and extrinsic psychological influences on the subjects themselves. These in turn may help determine adherence levels and influence behavioural change. This is despite the recommendations of Marcus et al.'s landmark study into the subject in 2000 that suggested five broad areas for further research into exactly these influences. (Marcus et al., 2000, p39)
A study into ERS patients in the West Midlands in 2006 concluded that,
"...to increase their success, there is a need to consider motivationally embellished EoP (Exercise on Prescription) schemes that pull from the tenets of SDT (Self Determination Theory) and aim to foster participants' basic psychological need satisfaction and self-determined motivational regulation". (Edmunds et al., 2006, p738)
A familiar concept in sports psychology is "self efficacy", originally developed by Albert Bandura, who states that,
"...efficacy beliefs largely determine whether people consider changing their health habits and whether they succeed in making and maintaining the change." (Bandura, 1997, p3)
A 2007 study showed an improved ability to manage the life consequences of cardiac disease, and to adhere to rehabilitation amongst patients exhibiting high exercise self efficacy. (Lau-Walker, 2007, pp 196-8)
WGW will be supervised by a qualified sports psychologist with undergraduate students adding support as part of their studies into exercise adherence. It will be open ended in time frame, with long term adherence the primary goal of the intervention.
As well as a lack of psychological support, most existing ERS schemes rely on a resource intensive model, involving supervised sessions by an exercise professional at a gym or leisure centre (Pavey et al., 2011, p2). This format in itself both places the desired behaviour change into an unfamiliar setting for most subjects and makes that setting less accessible to rural populations. In order to remove this further barrier to adherence, WGW will rely on an "at home" setting, in a rural area with "virtual peer" support, rather than the formal support or monitoring of an exercise or medical professional. It also involves no learning of unfamiliar exercise techniques as the base activity is walking, either alone or in small groups. It will rely heavily on empowerment and autonomy of the subjects themselves. Lay-led walking programmes were examined in a randomised controlled trial in 2001, that concluded,
"The effect of health walks compares favourably with other primary care based exercise schemes, including incentives, exercise on prescription and behavioural counselling." (Lamb et al., 2000, p251)
The final element in the intervention addresses one of the weaknesses of the lay led walking programmes reviewed by Lamb et al. These followed a fairly rigid structure of appointed supervised walks on routes with maps sent out by post and a "walk leader". (Lamb et al. p251) As this structured approach was accompanied by low adherence, these "health walks" may simply have become like sessions in a gym, but out of doors, relying on extrinsic influences rather than intrinsic motivation, and with "appointments" to be kept rather than a change in lifestyle to be adopted. In contrast, WGW will allocate participants to small groups who will be linked together in a social media setting. They will largely be in control of their own exercise time, which will be monitored by them, their peers and the programme leader via a free smartphone app, and / or a GPS watch provided by the GP practice on a loan basis. Exercise time will be evaluated cumulatively, allowing for periods of more and less intensive activity, free choice as to time of day and whether or not to participate in social interaction.
Part 2- Implementation, resources and Evaluation (Phases 3, 4 and 5)
The target demographic for WGW is individuals in the 45 - 54 years old age bracket, resident in the Stewkley, Quainton and Weedon wards of Aylesbury Vale District in North Buckinghamshire. (AVDC, 2012) This is an area of small villages and rolling farmland sandwiched between the larger towns of Aylesbury and Buckingham. There are no formal leisure or sports facilities in any of these villages apart from playing fields, although the countryside has many quiet lanes and is criss-crossed by a network of footpaths and bridleways. Initially 3 groups of 4-6 individuals will be selected from routine health screening tests made at the Whitchurch Surgery. Attempts will be made to group together individuals who are all deemed to be "at risk" from the negative health consequences of reduced physical activity, and who live near to one another. Despite the psychological support that will be offered, it is assumed that there will be a 50% drop out rate as has often been the case in ERS, and if this is the case new patients will be offered induction onto the scheme, and allocated to an appropriate group.
Each group will be then given an induction session, at which it will be made clear that what is being offered is not primarily a "medical" intervention. Recent thinking on health in later life, including Antonovsky's salutogenic paradigm accepts that certain definitions of "illness" as abnormal may be far from helpful in encouraging lifestyle change amongst members of this demographic. (Sidell, 2003, pp28-30) A degree of acceptance of frailties is to be a theme of the intervention, rather than a desire to improve empirical indicators of "normal" health. The session will be given by the intervention leading sports psychologist, accompanied by 1 or two students, with an NHS registered Health trainer present, along with a practice nurse and the public health practitioner as an observer. The session will be used to explore attitudes to exercise and physical activity amongst the group, compare experiences and investigate future opportunities to integrate more walking into the week's routine. The students will be charged with introducing the smartphone app to those with the facility, and instructing others on the use of the GPS watches. The health trainer will be available to discuss any exercise physiology issues as well as to suggest possible exercise routines as appropriate. Whether or not they possess a smartphone, the participants will record their walking sessions using the GPS tracking facility uploaded into a free exercise app with a social media focus called Endomondo.(www.endomondo.com) Endomondo both tracks exercise sessions in real time, plots them with mapping software, estimates calories burned, and allows participants to interact with a wider community of "friends" before, after and, in the smartphone version, during an exercise session. Once uploaded to the web interface, subscribers can view and comment on the workouts of others, seek new virtual exercise partners worldwide and join "challenges". In this way group members can support each other and the programme supervisors can remain informed of the progress of individuals in the group. An objective will be set to all participants of reaching the 150 minute weekly target for moderate activity as mentioned earlier, but engagement with the scheme on a long term basis will be the prime objective. Formal support after this first session will principally be psychological, with the professionals and students looking to help each individuals raise their self efficacy and take charge of their own activity levels. This will be accomplished by weekly telephone conversations, optional "in surgery" group follow-up sessions, and one to one "buddying" with an undergraduate student.
WGW pulls together a different range of resources than seen in most public health interventions. It seeks to influence behaviour change purely using psychological tools and self monitoring, but also offers the opportunity for peer to peer social support and the counselling of a qualified psychologist. The principal demand, apart from the provision of a number of GPS watches, is on the provision of the services of a registered sports psychologist experienced in the field of exercise adherence, and a number of sports science undergraduate students from a nearby university. Health monitoring will follow a parallel course, but will not be operated in co-ordination with the adherence / self efficacy programme. The relevant public health practitioner will be responsible for co-ordination, financial resource allocation (from the ERS budget) and gathering together the strands of evaluation.
In terms of evaluation, the originality of the scheme, and its nature as a pilot programme with small numbers of subjects in a very specific area, means that most value will be found in qualitative forms of evaluation. Phase 5 of the Nutbeam and Harris model calls for measurable and specific objectives. In this sense WGW has combined goals: firstly to improve the adherence to increased physical activity by subjects using a model of empowerment and self determination, and secondly to assess to what extent the intervention design itself contributes to achieving this objective. The virtual tools built into the intervention will enable empirical measurements of time spent in the walking activities, but as more groups are recruited a model such as the Hawe et. al planning and evaluation cycle would be appropriate. (Sidell & Douglas, 2012, p257-8) This model requires a cyclical relationship between the phases of planning and evaluation, enabling re-design of the intervention on the evidence of new information. For example it may be found that the need to use a GPS watch or a smartphone becomes an adherence obstacle rather than an aid to some partcipants, in which case process evaluation would suggest that some subjects may need less formal self reporting methods. All stakeholders would be part of the evaluation process, the psychologist, students, subjects and where appropriate family members of the subjects, but the public health practitioner would take the lead role in drawing this feedback process into any re-design of the intervention.
Part 3 - Public Health Policy Implications
In that the intervention seeks to operate against the risk factor of physical inactivity in an epidemiologically significant but certainly narrow demographic group, it could be seen as part of a "business as usual " approach in public health policy. (Jones, 2012, p 478). It certainly cannot be seen as a population wide health improvement or inequality reducing measure as it is presently constructed.The sources quoted above make clear that improving physical activity levels amongst all age groups is seen as a public health priority both in the UK and worldwide. The Heidelberg guidelines list a myriad of benefits for society and individuals through increased physical activity, not the least of which is "reduced health and social care costs" (WHO, 2002, pp 113-115). But despite making this a policy priority, successive governments in the UK have not been able influence the design of interventions that have proved effective. The same problem might be observed in the area of dietary choices or smoking - policymakers in these areas find it hard to influence individual behaviour sufficiently to effect change.
Whilst it remains within a broad spectrum of interventions aimed at improving physical activity levels, WGW certainly does have some policy implications in the specifics, however. It is a non-medically focussed intervention, that has within it a rejection of medically focussed measurements as it's goal, or that a trained professional is needed to "cure" the patient, even if this professional is a registered personal trainer. Were it to be successful, and the meta analyses and reviews of ERS quoted above suggest the "success" bar is extremely low, it would have implications for the status quo of health policy making that is trapped in a paradigm where qualified professionals from within the health service dominate. (Jones (2), 2012, p 414-5) Bringing sports psychologists into GP surgeries and using GPS watches as prescribed devices has implications with regards to ethics and patient confidentiality, possible advice conflicts and funding.
Perhaps the most important implication on policy lies outside the narrow scope of the health service. Transport policy, rights of way maintenance and regulation of the built environment are all implicated if citizens aspire to higher levels of fitness through simple forms of exercise in their locality. If policymakers concede that an environment conducive to taking exercise may help mitigate some of the £11.7 billion spent annually on treating type 2 diabetes (diabetes.co.uk, 2014), even in the WGW locality, protected well lit pavements, well cleared rights of way and rural cycle routes may have to become local policy priorities.
Part 4 - Critical Reflection
WGW takes an innovative approach to an accepted public health issue. It is "light touch" in patient contact time and compared to conventional ERS is not resource hungry. In a climate where healthcare resources are stretched, funding allocations are highly competitive and medical treatment innovations abound, this apparent strength may be a weakness of the idea. Officials viewing from the perspective of the medical or even the socially constructed model of public health may see the intervention as frivolous, and without clearly measurable objectives that can be fed into wider policy decisions. If this is the case the intervention may never get funding.
Calling on the discipline of sports psychology in dealing with patients under treatment brings a range of difficulties. Apart from in professional sports clubs or national sporting organisations there may be little existing contact between GP's and Sports Psychologists, or the psychology department of universities, and the public health practitioner leading the planned intervention may struggle to pull together these human resources. Psychologists may find they are in the difficult area of offering advice to patients that calls into question the disease / treatment paradigm of the GP, or that crosses into the medical domain. This poses an ethical problem that will need very careful managing and clear guidelines. Launching individuals into increasing their physical activity will require that conventional health screening continues as normal, but the intervention team will not be privy to such information under patient confidentiality.
The software and social media interface may not suit all subjects in the target age group. Smartphone ownership is far from general and, although GPS watches are not expensive in comparison with in-home medical equipment, they require information download onto a home computer and internet access to use the virtual tools and social networking features. These all may be adherence barriers for some subjects and give the intervention a selection bias to those of higher socio-economic standing.
Despite these barriers, WGW has some significant advantages, particularly in comparison to existing ERS schemes. As a self-motivating regular exerciser, the author was struck in preparing this intervention plan by the poor adherence results and low exercise level thresholds achieved by ERS throughout the UK, and convinced by evidence concerning the role that psychological support geared towards self motivation could play. WGW has deliberately been designed as a pilot scheme with the narrow aim of improving adherence levels by allowing psychological models with proven success in the field of sports psychology to contribute. Empowerment of patients in their own care is now a significant theme in health policy, and WGW at its most ambitious will aim to encourage subjects to re-identify themselves in respect of their own personal health. The use of small clusters of subjects in a geographical area with few formal exercise facilities means that the intervention is very scaleable, and could be used in other locations, the major difficulty being the availability of a sports psychologist in a location for induction.
Finally, in designing this intervention the author was wary of the advice of not indulging in "blue sky" thinking, and despite thorough research, could not find evaluations of similar programmes elsewhere in the UK. This contributed to design of an intervention that employed personal knowledge and experience as well as information from a prior Open University course on Sports Psychology. Not having directly presented the psychological models available in the text may be a weakness, but it was felt that first space was not available and secondly, in the real world, the psychologist responsible would adapt the models to suit the individuals themselves.
3276 words includes in-text references
References
K311 Course Materials
Sidell & Douglas, 2012: Sidell, M. & Douglas, J., 2012, 'Chapter 9: Using evidence to plan and evaluate public health interventions', in, Jones, L. & Douglas, J. (eds), Public Health: building innovative practice, pp 71-98, Sage Publications for The Open University, Milton Keynes, UK, 2012.
Sidell, 2003: Sidell M., 2003, 'Older People's Health: Applying Antonovsky's Salutogenic Paradigm', in, Douglas J. et al (eds) A reader in promoting public health, challenge and controversy, 2nd edition, pp 77-88, Sage publications for The Open University, Milton Keynes, UK, 2003, 2010, UK.
Jones, 2012: Jones, L., 'Chapter 15: 'Building Healthier futures: barriers and enablers', in, Jones, L. & Douglas, J. (eds), Public Health: building innovative practice, pp 71-98, Sage Publications for The Open University, Milton Keynes, UK, 2012.
Jones (2), 2012: Jones, L., 'Chapter 14: 'Understanding and Influencing Polich Change', in, Jones, L. & Douglas, J. (eds), Public Health: building innovative practice, pp 71-98, Sage Publications for The Open University, Milton Keynes, UK, 2012.
Journal Articles
Hanson et al., 2013: Hanson, C.L. et al., 2013, 'An evaluation of the efficacy of the exercise on referral scheme in Northumberland, UK: association with physical activity and predictors of engagement. A naturalistic observation study.' in BMJ Open (2013;3:e002849 doi:10.1136/bmjopen-2013-002849) online at http://bmjopen.bmj.com/content/3/8/e002849.short . Accessed 24th May 2014.
Pavey et al. 2011: Pavey, T. et al., 'Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta analysis' in BMJ Open (2011;343:d6462 doi:10.1136/bmj.d6462) online at http://bmjopen.bmj.com/. Accessed 24th May 2014
Marcus et al., 2000: Marcus, B., et al, 2000, 'Physical activity behaviour change: issues in adoption and maintenance', in Health Psychology, vol 19 (2000) no. 1 (suppl) pp 32-41, The American Psychological Association, USA, 2000.
Edmunds et al, 2006: Edmunds, J., Ntoumanis, N., Duda, J., 'Adherence and well-being in overweight and obese patients referred to an exercise on prescription scheme: A self-determination theory perspective', in Psychology of Sport and exercise, vol. 8 (2007), pp 722-740, UK, 2007.
Bandura, 1997: Bandura, A., 'Self Efficacy', in Harvard Mental Health Letter, vol 13., March 1997, Issue 9, p4. Harvard University, Cambridge, Mass., USA, 1997.
Lau-Walker, 2007: Lau-Walker, M., 'Importance of illness beliefs and self efficacy for patients with coronary heart disease', in Journal of Advanced Nursing, vol.60 (2) pp. 187 -198, UK, 2007.
Lamb et al., 2001: Lamb, S.E. et al., 'Can lay-led walking programmes increase physical activity in middle aged adults? A randomised controlled trial', Journal of Epidemiology and Community Health, 2002, vol. 56, pp 246-252, UK, 2002.
Other Published Material
Scholes & Mindell, 2013: Scholes, S. & Mindell, J., 'Is the adult population in England active enough? Initial results from the Health Survey for England 2012', Health & Social Care Information Centre, London, 2013.
WHO, 2002: World Health Organisation, 2002, 'ANNEX 4: The Heidelberg guidelines for promoting physical activity among older persons' 2002, Keep Fit For Life, pp. 112-119, Academic Search Complete, EBSCOhost, accessed 24th May 2014.
Murphy et al., 2010: Murphy S. et al., 'The evaluation of the National Exercise Referral Scheme in Wales', Welsh Assembly Government Social Research, 2010. Crown Copyright, UK, 2010.
Websites
Endomondo.com : "Free sports community based online software for real time GPS tracking of cycling, running etc." online at http://www.endomondo.com/ Accessed 29th May 2014.
Diabetes.co.uk : "Cost of diabetes treatment in the UK 2010" online at http://www.diabetes.co.uk/cost-of-diabetes.html. Accessed 28th May 2014.
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