Summary

Physical activity can delay or prevent chronic diseases such as vascular disease, which includes heart disease, stroke, diabetes and kidney disease. The majority of adults in England do not meet the government recommendation of at least 30 minutes per day of moderate-intensity activity on at least five days per week.

The NHS has started Health Checks, in which everyone between 40 and 74 years is invited for an assessment of their risk of vascular disease and offered appropriate management of risk. The Health Checks are an ideal opportunity to deliver brief physical activity advice (interventions) to promote physical activity to large numbers of people in this age group.

In this research programme we will develop and test interventions that aim to promote moderate activity such as brisk walking that could be delivered by a practice nurse in a few minutes during a Health Check. Very brief advice can also be given during routine consultations in primary care and potentially reach many millions of people. Brief advice may involve “advice” of various kinds and to be effective it is likely that participants will actively be involved.

The research programme includes several inter-related strands of work. We will review the literature to identify promising brief interventions and present our findings to an expert group consisting of researchers, practitioners, primary care commissioners and people in the target age group for Health Checks. We will also interview general practice staff and patients who attend for Health Checks and observe some consultations to understand how brief interventions can best be fitted into such consultations. We will develop and test several brief interventions before we move to a large trial to assess how well the most promising of these works in practice. Because people cannot tell precisely how active they are from day to day, participants in our studies will be asked to wear physical activity monitors which are very sensitive to the amount of movement. We will also measure the cost of delivering the interventions, including the time it takes, and their effectiveness. An important component of the research programme will involve using methods from health economics to assess whether the interventions we develop are good value for money.

Background

Physical activity can prevent or delay vascular disease

Vascular disease, which includes coronary heart disease, stroke, diabetes and kidney disease, is common. It affects more than four million people in England, causes one out of three deaths and one out of five hospital admissions. It also contributes to health inequalities (1). Unhealthy behaviours such as a sedentary lifestyle are important risk factors for these diseases (2). Adopting a healthier lifestyle could reduce the risk of developing these diseases. The available data about physical activity levels among English adults show that there is much room for improvement.

The current recommendation for adults is that they should aim to take 30 minutes of moderate intensity physical activity, e.g., brisk walking, on at least five days per week. This can be broken down in shorter sessions of at least ten minutes (3). The Health Survey for England 2006 found that only 46% of men and 35% of women between 35 and 44 years met this recommendation. This fell to 21% of men and 16% of women aged 65 to 74 years (4). These figures are based on self-reports of physical activity, and people tend to overestimate how active they are. When activity was measured objectively with an accelerometer, only 6% of men and 4% of women met the recommendation.

Health checks offer a good opportunity for very brief physical activity advice

The NHS has recently introduced Health Checks which are offered to all adults between 40 and 74 years. They can be performed by practice nurses and other practitioners such as community pharmacists. Health Checks include an assessment of a person’s risk of vascular disease and advice and treatment tailored to the person’s risk. The Health Checks offer an ideal opportunity to deliver brief physical activity advice of approximately five minutes to a large proportion of the population. Very brief physical activity advice is relatively easy and inexpensive to implement on a large scale, and a small effect could translate into a significant public health benefit.

What is known about physical activity interventions?

There are several literature reviews about the effects of interventions to promote physical activity. A review by the National Institute of Health and Clinical Excellence concluded that brief advice by primary care practitioners showed promise, but there was uncertainty about the most effective approaches among groups at higher risk of chronic disease (5). The US Preventative Services Task Force stated that it was not yet clear whether physical activity counselling in primary care is effective; they recommended more research on this topic (6). Reviews of walking interventions and physical activity advice in routine primary care consultations show that they can be effective in the short term (7-12).

Why do we need more research?

There is still a need for more research. The precise contents of interventions are often not detailed enough to allow others to replicate the intervention. Many studies have had a sizeable proportion of participants who did not complete the study, affecting the findings of the research. Measures of physical activity have often been by self-report, which can be unreliable.

It is unclear to what extent the findings of more intensive interventions can be generalised to very brief physical activity delivered as part of the Health Checks or routine primary care consultations. Our research programme, funded by an NIHR programme grant, will gain more insight into the cost and effectiveness of very brief interventions to promote physical activity. 

Aims and objectives

The aim of our research programme is to develop and evaluate very brief interventions to increase physical activity that could be delivered by a practice nurse in a Health Check or another primary care consultation.

Our objectives are:

1. To estimate from existing studies and reviews the cost and effectiveness of very brief physical activity interventions.
2. To identify a shortlist of the most promising very brief interventions.
3. To determine how very brief physical activity interventions can best be integrated into primary care consultations.
4. To develop and pilot intervention materials.
5. To test the feasibility, acceptability and potential efficacy of the most promising interventions.
6. To estimate from new trial data the cost and effectiveness of the best-bet brief intervention.
7. To develop an economic model of the cost-effectiveness of very brief physical activity interventions.

Research plans

The research programme consists of five workstreams that are interconnected. Workstream 1, 2 and 5 started in January 2011 and we aim to start workstream 3 in 2012.

Workstream 1 examines the existing evidence on the cost and effectiveness of very brief behaviour change interventions to increase physical activity. One example of monitoring one’s physical activity levels, for instance by wearing a pedometer. Workstream 2 uses qualitative methods to investigate how very brief interventions to increase physical activity can best be integrated into routine clinical practice. At the end of these two workstreams we will select the most promising interventions to be tested further.

In workstream 3, protocols, materials and training manuals for the interventions will be developed and piloted. Furthermore, we will carry out preliminary tests of efficacy for these interventions. The best-bet intervention will be selected for evaluation in a large trial. In Workstream 4, we will conduct an explanatory trial to evaluate the best-bet intervention. Workstream 5, which is economic modelling, underpins the whole programme.

Planned outputs

The outputs from our research programme will include:

• Literature reviews of the effectiveness of brief interventions for physical activity.
• Materials for promising very brief interventions for practitioners and patients.
• Estimates of the cost and effectiveness of the best-bet brief intervention based on trial evidence.
• Training for practice nurses in delivering the intervention and participating in research
• An economic model of the cost and effectiveness of very brief interventions to increase physical activity.

References

 (1)   Department of Health. Putting prevention first. Vascular checks: risk assessment and management. London: Department of Health; 2008.

(2)   Strong K, Mathers C, Leeder S, Beaglehole R. Preventing chronic diseases: how many lives can we save? The Lancet 2005;366:1578-82.

(3)   Department of Health. At least five a week: Evidence on the impact of physical activity and its relationship to health. A report from the Chief Medical Officer. London: Department of Health; 2004.

(4)   Aresu M, Bécares L, Brage S, Chaudhury M, Doyle-Francis M, Esliger D, Fuller E, Gunning N, Hall J, Hirani V, Jotangia D, Mindell J, Moody A, Ogunbadejo T, Pickup D, reilly N, Robinson C, Roth M, Wardle H, et al.th Survey for England 2008. Volume 1: Physical activity and fitness. Leeds: The NHS Information Centre for health and social care; 2009.

(5)   National Institute for Health and Clinical Excellence. Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers and community-based exercise programmes for walking and cycling. Public Health Intervention Guidance no. 2. London: National Institute for Health and Clinical Excellence; 2006.

(6)   Eden K, Orleans T, Mulrow C, Pender N, Teutsch S. Does counseling by physicians improve physical activity? A summary of the evidence for the US Preventative Services Task Force. Ann Intern Med 2002;137:208-15.

(7)   Ogilvie D, Foster CE, Rothnie H, Cavill N, Hamilton V, Fitzsimons CF, on behalf of the Scottish Physical Activity Research Collaboration (SPARColl). Interventions to promote walking: systematic review. BMJ 2007;334:1204-14.

(8)   Hillsdon M, Thorogood M, Anstiss T, Morris J. Randomised controlled trials of physical activity promotion in free living populations: a review. J Epidemiol Community Health 1995 October;49(5):448-53.

(9)   Petrella R, Latanzio C. Does counseling help patients get active? Systematic review of the literature. Canadian Family Physician 2002;48:72-80.

(10)   Simons-Morton DG, Calfas KJ, Oldenburg B, Burton NW. Effects of interventions in health care settings on physical activity or cardiorespiratory fitness. Am J Prev Med 1998;15(4):413-30.

(11)   Eakin EG, Glasgow RE, Riley KM. Review of primary care-based physical activity intervention studies: effectiveness and implications for practice and future research. Journal of Family Practice 2000 February;49(2):158-68.

(12)   Lawlor D, Hanratty B. The effect of physical activity advice given in routine primary care consultations: a systematic review. Journal of Public Health Medicine 2001;23:219-26.