Promoting physical activity within healthcare systems globally

Purpose: To provide reasoning, evidence and strategies for how physical activity can be promoted within healthcare systems.

Description: The World Health Organization Global Action Plan on Physical Activity (WHO GAPPA) has set a target of a 15% relative reduction in the global prevalence of physical inactivity in adults and in adolescents by 2030. To achieve this target, the GAPPA sets out 20 policy actions with action 3.2 recommending countries implement and strengthen physical activity assessment and counselling as part of universal health care. However, healthcare systems around the world are still struggling to implement and scale-up physical activity promotion as part of routine care. Common barriers reported by health professionals include insufficient resources, time, knowledge, skills, training, protocols, reimbursement, and organisational routines that do not enable physical activity promotion to be embedded into care. This symposium will present public health initiatives and research underway in three countries (the Netherlands, Australia, and United Kingdom) that have sought to train health professionals and embed physical activity promotion within healthcare systems and evaluated the effectiveness of this work. We will present current evidence on effectiveness of physical activity promotion in healthcare, present models of brief physical activity counselling that can be used in healthcare (e.g., 5As and COM-B) and strategies for training the health workforce including links to free online resources. We will share learnings from our different contexts about what has worked and what hasn’t worked and what we think could be improved. A moderated discussion will facilitate engagement with the audience to discuss some of the challenges and opportunities to implementing and scaling up physical activity promotion within healthcare systems. We aim for attendees to take away knowledge and resources on physical activity promotion for use in their local healthcare context to help improve physical activity promotion in healthcare globally.

Chair: Associate Professor Leanne Hassett, The University of Sydney

Presenters:
Dr Ingrid Rosbergen, University of Applied Sciences, Leiden, Netherlands
Development of the person-centered Keep Moving Support Tool integrating behavioral change science and design research.

Dr Anita Feleus, Rotterdam University, Netherlands
How to support health professionals to effectively integrate a physical activity-counselling tool in clinical practice.

Associate Professor Leanne Hassett, The University of Sydney
Adapting and implementing the 5As model of physical activity counselling within hospital settings in Australia.

Professor Nicole Freene, University of Canberra, Australia
Scaling up Measure It!: what is the evidence.

Sarah Durkin, Sheffield Hallam University, The United Kingdom
Embedding Physical Activity in Healthcare through the Physical Activity Clinical Champions Programme: co-design and implementation.

Moderator: Professor Catherine Sherrington, The University of Sydney

Abstract 1:

Title: Development of the person-centered Keep Moving Support tool integrating behavioral change science and design research.

Authors
ICM Rosbergen1, AE Hesselink1,, A Feleus2, G Kloek3,4, PC Siemonsma1

Corresponding author
1Ingrid Rosbergen, PHD, Research group Self-Management in Physical Therapy and Human Movement Care, Department of Physical therapy, Faculty of Health, University of Applied Sciences Leiden, Leiden, The Netherlands; Tel: +31 (0)6 3927 3941; email: Rosbergen.i@hsleiden.nl

Affiliations
1. Research group Self-Management in Physical Therapy and Human Movement Care, Department of Physical Therapy, Faculty of Health, University of Applied Sciences Leiden, The Netherlands
2. Research Center Innovations in Care and Department of Physiotherapy, Rotterdam University of Applied Sciences, the Netherlands
3. Research group Healthy Lifestyle in a Supporting Environment and Faculty of Health, Nutrition & Sport, The Hague University of Applied Sciences, The Hague
4. Research group Smart and Health School, Saxion University of Applied Sciences, Enschede, The Netherlands

Background
Supporting patients to achieve healthy physical activity levels can enhance their meaningful community participation. However, healthcare interventions rarely result in sustained physical activity. Person-centered interventions that incorporate behavioral science to empower patients’ self-management are needed.

Purpose
To develop a Keep Moving Support tool that supports healthcare professionals in using behavioral change techniques to enhance patients’ self-management in achieving sustained physical activity.

Methods
The theoretical Behavior Change Wheel, including the COM-B (Capability, Opportunity, Motivation and Behavior component), and a scoping review on effective behavior change techniques (19 reviews, 33 RCTs) formed the framework for the design of the support tool. Design research using context mapping sessions (8 with 38 clients) and storytelling (12 clients, 11 professionals) guided the creation of physical activity profiles. Co-creation sessions (n=3) with professionals shaped the decision support tool. Prototypes were tested, followed by a feasibility study with healthcare professionals.

Results
The combined data led to the Keep Moving Support tool including 6 physical activity profiles and a behavior change decision tool. Patients use the physical activity profiles to outline their personal movement behavior through circling what they recognize about themselves. In the subsequent consultation, healthcare professionals and patients discuss the profiles and the decision tool leads them stepwise to person-centered physical activity counseling and behavior change techniques. Together, they arrange actions to enhance physical activity. The feasibility study involving 52 patients indicated that the tool supports an active patient role, insight into needs and context, and shared decision-making, but health professionals perceived delivery of behavior change techniques as challenging.

Conclusions
The Keep Moving Support tool holds promise to support professionals in physical activity counseling.

Practical implications
Supporting professionals in applying person-centered behavior change techniques can enhance patients’ self-management in physical activity.

Funding
Taskforce for Applied Research SIA (RAAK.PUB05.029), Vital Delta (SPR.VG01.006) and Medical Delta.

Abstract 2:

Title: How to support health professionals to effectively integrate a physical activity-counselling tool in clinical practice.

Authors
A Feleus1, ICM Rosbergen2, M Bik2, JM Dallinga3, S van Rongen3, PC Siemonsma2, AE Hesselink2

Affiliations
1. Research Center Innovations in Care and Department of Physiotherapy, Rotterdam University of Applied Sciences, the Netherlands
2. Research group Self-Management in Physical Therapy and Human Movement Care, Department of Physical Therapy, Faculty of Health, University of Applied Sciences Leiden, The Netherlands
3 Research group Healthy Lifestyle in a Supporting Environment and Faculty of Health, Nutrition & Sport, The Hague University of Applied Sciences, The Hague and Research group Smart and Health School, The Netherlands

Corresponding author
1Anita Feleus, PHD, Research Center Innovations in Care and Department of Physiotherapy, Rotterdam University of Applied Sciences, the Netherlands
e-mail: a.feleus@hr.nl
phone: +31-6 36155096

Background
Facilitating an active lifestyle within healthcare is experienced as both important and challenging. The Keep Moving Support Tool (KMS-tool) was developed in co-creation with patients and professionals to support physical activity counselling and seems successful. However, application in daily clinical practice needs attention.

Purpose
To support physiotherapists in the use of the KMS-tool in clinical practice using an implementation strategy and participative action research.

Methods
The implementation strategy was developed using the existing models, CFIR and COM-B, and included interviews and co-creation sessions. Participative action research was conducted in 3 physiotherapy clinics in primary care. Through individual and group contact, barriers and facilitators for implementing the KMS-tool were identified and addressed by the researchers.

Results
Seven physiotherapists included 20 patients. Information was gathered through 14 observations, 19 interviews (12 patients; 7 physiotherapists), 9 clinic meetings (3/practice), electronic patient files (n=20), and learning community meetings (n=2).
Reported barriers were unfamiliarity with physical activity counselling, uncertainty about meeting patient expectations, lack of time, not part of routine, feeling incompetent incorporating behaviour change techniques, and lacking communication skills.

Solutions were explored and blended education and supporting materials developed along the way to support professionals’ beliefs, knowledge and skills. They included: an e-learning including training of the KMS-tool and implementation strategies, adjustments to the KMS-tool to improve user-friendliness promotional materials, and a training day on communication techniques and behaviour change. A hybrid implementation effect study with the adjusted KMS-tool is currently underway with results available at time of presentation.

Conclusions
By using Participative Action Research, the KMS-tool and its implementation were adapted to the needs of physiotherapists and patients.

Practical implications
Participatory Action Research can assist in tailoring support for professionals in integrating physical activity counselling in clinical practice.

Funding
Dutch Taskforce for Applied Research SIA (RAAK.MKB15044), Vital Delta (SPR.VG01.006) and Medical Delta.

Abstract 3:

Title: Adapting and implementing the 5As model of physical activity counselling within hospital settings in Australia.

Author
Hassett L1,2

Affiliations
1 Faculty of Medicine and Health, The University of Sydney, Sydney, Australia;
2 Sydney Health Partners, Sydney, Australia

Correspondence
Leanne Hassett, PhD, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia;
e-mail: leanne.hassett@sydney.edu.au
phone: +61408241708

Background
The Brief Physical Activity Counselling by Physiotherapists (BEHAVIOUR) trial aims to support physiotherapists working in a health district in Australia to deliver the 5As model of physical activity counselling within routine hospital care.

Purpose
The purpose of this paper is to describe the implementation strategies used with physiotherapy teams within the BEHAVIOUR trial and the adaptations to the 5As physical activity counselling required to meet the needs of the local context.

Methods
A hybrid type II implementation-effectiveness cluster randomised controlled trial. Thirty teams of physiotherapists across six hospitals were randomised to receive implementation support immediately or delayed. A survey of physiotherapists was conducted prior to the trial commencing as a local behavioural diagnosis framed within the COM-B behaviour change theoretical model. The Consolidated Framework for Implementation Research (CFIR) and the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME) were used to consider suitability of implementation strategies and adaptations required to the 5As counselling intervention to be context specific and have potential for scalability within the Australian healthcare setting.

Results
Survey of 84 physiotherapists identified implementation strategies need to primarily build clinicians’ Capabilities (knowledge and skills) and Opportunities (resources for community referral) to deliver physical activity counselling. The following implementation strategies were delivered to teams of physiotherapists; education, training, tailored strategies to address community referral barriers, creation of a learning collaborative across the district, team facilitation, and audit and feedback. Identified adaptations to physical activity counselling included adjusting for different patterns of practice across different settings (e.g., inpatient and outpatient), student involvement and patients with diverse health conditions and cultural backgrounds.

Conclusions
Context is important when considering implementation and adaptation of physical activity interventions.

Practical implications
Context needs to be evaluated as physical activity interventions are scaled-up.

Funding
Australian MRFF preventive health grant (APP1201086).

Abstract 4:

Title: Scaling up Measure It!: what is the evidence.

Author
Freene, N1

Affiliations
1 Health Research Institute, University of Canberra, ACT, Australia

Correspondence
Nicole Freene, Health Research Institute, University of Canberra, ACT, Australia
e-mail: Nicole.Freene@canberra.edu.au
phone: +61 2 6201 5550

Background
Lack of time to promote physical activity within consultations is the biggest reported barrier to health professionals giving this advice.

Purpose
To describe the development and evaluation of Measure It!, a very brief intervention for physical activity behaviour change. Evidence of scaling-up will also be provided.

Methods
The Measure It! intervention (<5 min) includes an objective and self-report measure of physical activity plus very brief physical activity advice provided by a health professional. The intervention has been developed and refined using a systematic review, cross-sectional survey, pilot randomised trial and type I effectiveness-implementation randomised trial.

Results
Our systematic review indicates that in up to one-third of studies, simply measuring physical activity levels in control groups as part of randomised studies of physical activity interventions, increases physical activity behaviour. Our survey of Australian cardiac rehabilitation health professionals found that if they measured patients’ physical activity levels they were 8 times more likely to frequently promote physical activity to patients. In our pilot study with physiotherapists in primary care (n=40), we found that more frequent measurement of physical activity resulted in increased physical activity. Preliminary results from our type I hybrid trial in cardiac rehabilitation (n=190) has found that patients value the health professional check in about their physical activity, providing them with the opportunity to reflect and be reassured about their activity levels. Health professionals like the structure of the intervention, find it easy to deliver, and it fits into their existing workflow. In July 2024, Queensland Health adopted Measure It! in all mental health services across the state.

Conclusions
Measure It! is novel, with potential for large-scale impact.

Practical implications
With minimal training, skills and equipment required, Measure It! could be utilised by many health professionals, in a variety of settings.

Funding
Australian MRFF Cardiovascular Health Mission grant (MRFF2015953).

Abstract 5:

Title: Embedding Physical Activity in Healthcare through the Physical Activity Clinical Champions Programme: co-design and implementation

Authors
Durkin, S1

Affiliations
1The Advanced Wellbeing Research Centre (AWRC), Sheffield Hallam University, Sheffield, United Kingdom.

Corresponding author
Sarah Durkin, 1The Advanced Wellbeing Research Centre (AWRC), Sheffield Hallam University, Sheffield, United Kingdom.
e-mail: s.durkin@shu.ac.uk
phone: 0114 225 4049

Background
A substantial proportion of the UK population fails to meet national physical activity guidance and those with long term health conditions are significantly more likely to be inactive. Healthcare professionals have been identified as key agents in supporting physical activity behaviour change but limited confidence, knowledge and skill in this area may prevent their impact from being optimised.

Program Delivery
The Physical Activity Clinical Champions (PACC) programme was launched in 2014, it is a national education programme that was initially funded by Sport England and delivered by the Office for Health Improvement and Disparities in England. The PACC programme is a peer-to-peer education programme that is delivered by a national network of trained clinicians who delivered a standardised education session to other healthcare professionals. The training aims to increase healthcare professionals’ knowledge, skills, and confidence to integrate conversations about physical activity into routine clinical practice in England, with the longer-term aim of contributing to increases in physical activity levels at population-level.

Evaluation
The programme evaluation indicates that the training is well received by healthcare professionals, and is effective in increasing their confidence, knowledge and skills. The training attracts healthcare professionals who don’t routinely talk about physical activity in their clinical interactions. The programme has scaled and to date, over 40,000 professionals in England have received training.

Conclusions
The programme is now under new leadership and our challenge is to transform it into a sustainable, co-designed and equitable model.

Practical implications
In this session we will discuss the co-design process, including ways in which stakeholders were involved and how the prototype model was developed. We’ll draw on implementation science frameworks as we describe how the model was shaped, tested and refined. We will also share plans for further scale and spread.

Funding
This program was initially funded by Sport England.