Att främja arbete med fysisk aktivitet hos patienter med metabola riskfaktorer i primärvård.
Fysisk aktivitet på recept som behandlingsmetod vid vårdcentral eller som förstärkt stöd av fysioterapeut.

Project number : 267981
Created by: Stefan Lundqvist, 2019-04-12
Last revised by: Stefan Lundqvist, 2019-06-27
Project created in: FoU i Västra Götalandsregionen

PublishedPublished

1. Översiktlig projektbeskrivning

Engelsk titel

Promoting physical activity in primary health care.
Physical activity on prescription in a health care centre setting or with enhanced support by physiotherapist.

Populärvetenskaplig sammanfattning av projektet

Bakgrund:

Fysisk aktivitet på recept (FaR) används för att öka fysisk aktivitetsnivå och därigenom uppnå positiva hälsoeffekter. FaR är dock underutnyttjat som behandlingsmetod inom Svensk hälso- och sjukvård.

Övergripande syfte:

Att utvärdera 2 olika FaR-behandlingsstrategier för 444 fysiskt inaktiva patienter med metabola riskfaktorer gällande fysisk aktivitetsnivå, metabol hälsa och hälsorelaterad livskvalitet. Att belysa vilka patienter som har störst nytta av FaR-behandling och vilka prediktorer som har betydelse för ökad fysisk aktivitetsnivå samt att göra en kostnadseffektivitetsberäkning av de 2 FaR-behandlingsstrategierna.

Ingående studier:

  1. Att utvärdera 6 månaders FaR-behandling på vårdcentral gällande fysisk aktivitetsnivå, metabol hälsa och hälsorelaterad livskvalitet. Att utvärdera sambandet mellan fysisk aktivitet och hälsoeffekter.
  2. Att utforska predicerande faktorer till ökad fysisk aktivitetsnivå vid 6 månaders uppföljning av FaR-behandling. Att belysa vilka patienter som ökar sin fysiska aktivitetsnivå mest.
  3. Att utvärdera 2 års FaR-behandling via fysioterapeut alternativt vårdcentral gällande fysisk aktivitetsnivå, metabol hälsa och hälsorelaterad livskvalitet.
  4. Att utvärdera kostnadseffektivitet av 3 års FaR-behandling via fysioterapeut jämfört med FaR-behandling på vårdcentral.

Förväntat resultat:

Ökad kunskap kring FaR-behandlingseffekter och prediktorer för ökad fysisk aktivitet ger möjlighet att bättre individualisera FaR-behandling på adekvat nivå. Kunskap kring FaR-behandlingens kostnadseffektivitet ger beslutsunderlag för en bredare implementering inom Svensk hälso- och sjukvård.

Vetenskaplig sammanfattning av projektet

Background:

There is strong evidence that inadequate physical activity (PA) is associated with increased risk of developing lifestyle-related diseases and premature death. Metabolic syndrome (MetS) is not consistently defined, but includes overweight, abdominal obesity, insulin resistance, dyslipidaemia, and hypertension in various combinations. The presence of MetS carries a high risk for developing cardiovascular disease and type 2 diabetes.

PA – definition and health impact: The definition of PA is ”any bodily movement produced by skeletal muscles that results in energy expenditure” and can be categorized as e.g. a household, occupational, leisure time, and sporting activity. Exercise is PA with the objective to improve or maintain physical fitness components and is categorized in terms of the type, frequency, duration, intensity, and purpose. The internationally recommended minimum level of PA is moderate-intensity aerobic PA 150 min per week or, alternatively, vigorous-intensity aerobic PA 75 min per week, which has been associated with a clinically relevant risk reduction. A sufficiently high physical activity level has the possibility to affect all components in MetS.

PA and PAP as a method of treatment: Despite the evidence-based positive effects of regular PA on health, implementing PA as an integrated method of treatment in health care remains a major challenge. The Swedish National Board of Health’s guidelines for disease prevention methods recommends the use of individual-based dialogue, written information, training diaries, a pedometer, and structured follow-up when the patient´s PA-level is insufficient. An example of such a treatment strategy is physical activity on prescription (PAP), which is individually tailored for each patient and prescribed for preventive and therapeutic purposes as a first-line treatment. PAP-treatment has been shown to increase the PA level in patients with metabolic risk factors visiting primary health care. Meta-analyses of international PAP studies show varying results, when comparing increased PA levels with usual care and there is uncertainty due to the lack of high quality studies. Swedish lifestyle interventions, including PA, has shown to be cost-effective and the Swedish PAP intervention method has positive effects on PA levels, body composition, cardio metabolic risk factors, and health related quality of life (HRQOL). Although scientific evidence has resulted in clinical treatment guidelines and there are some evaluated Swedish PAP studies, PA is still underutilized as a treatment strategy in Swedish health care. There is still a lack of knowledge about PAP interventions and further studies are needed evaluating clinical feasible PAP strategies on a large sample.

PAP-treatment and behaviour change: The PAP-treatment in Sweden is part of the patient-centred care and the patient-centred counselling approach of motivational interviewing (MI) is often used as a tool to motivate and encourage the patient to change PA behaviour. The PAP method is based on theory-based change models, primarily the transtheoretical model and social cognitive theory. However the reasons why PA interventions are effective are not fully understood based on the factors that intervene between interventions and PA behaviour change. There is still uncertainty regarding the best methods of promoting PA and the factors affecting long-term adherence, correlated to improved effects on MetS parameters. To look at intervening causal variables (e.g. self-efficacy), has been a way of understanding possible correlates of PA in the pathway between an intervention and the outcome. The mediating variable model declare that changes in correlates of PA possibly lead to changes in physical activity. The literature concerning the role of correlates of PA change in experimental PA studies is, however, relatively elusive. More research is required about possible correlating factors and PA behaviour.

In primary care in the city of Gothenburg, health care centers have implemented PAP-treatment, individualized for patients with metabolic risk factors, with the purpose of increasing the PA level and health benefits. This specific model of PAP-treatment in daily clinical work has not been evaluated.

Aims and objectives:

The general aim of this thesis is to evaluate two different PAP-treatment strategies in order to increase the PA level of patients, physically inactive, with metabolic risk factors and to explore correlating factors possibly predicting response or non-response to increased PA level. In a health economics study, the cost-effectiveness of PAP with two different strategies will be evaluated.

Objectives:

  • To explore the association between PAP-treatment and the PA level of patients with metabolic risk factors and the relationship between changes in the PA level and changes in metabolic risk factors and HRQOL at the 6-month follow-up (Study 1).
  • To explore factors associated with PA-level change in a 6-month period of PAP-treatment in order to highlight potential predicting correlates to increased PA-level. (Study 2).
  • To evaluate a one year enhanced support with physiotherapist for patients, non-responding to PAP-treatment at 6 months follow-up in a primary health care centre setting, regarding PA level, fitness, metabolic health effects and HRQOL (Study 3).
  • To evaluate cost-effectiveness of enhanced support from physiotherapist compared to PAP-treatment at the health care centre in a two years perspective (Study 4).

Clinical implication:

This thesis will indicate how different PAP strategies in primary health care affects the level of PA, metabolic health and HRQOL for physically inactive patients with metabolic risk factors. Highlighting possible correlates of PA in an early stage give the opportunity to support the patient in the behavioural change process and individualize the PAP-treatment on an adequate degree to increase PA level. A health economic analysis will illuminate the cost-effectiveness of the PAP-treatment strategies.

Ethical aspects:

The overall possible risks when intervening with physical activity are considered to be very small. The patient may experience some discomfort in exercising, a feeling considered to be a natural reaction initially. A certain discomfort can also be experienced in blood sampling. The patient got information about the possibility to receive treatment with PAP and to be included in the study by written information and orally by their caregiver. There are ethical approval for all studies.

Typ av projekt

Forskningsprojekt

MeSH-termer för att beskriva typ av studier

checked Longitudinella studier (Longitudinal Studies)
checked Prospektiva studier (Prospective Studies)
checked Randomiserad klinisk prövning (Randomized Controlled Trial)


(Only selected options are displayed. Click here to display all options)

MeSH-termer för att beskriva ämnesområdet

information Added MeSH terms
Exercise
Physical activity which is usually regular and done with the intention of improving or maintaining PHYSICAL FITNESS or HEALTH. Contrast with EXERTION which is concerned largely with the physiologic and metabolic response to energy expenditure.
Health Behavior
Behaviors expressed by individuals to protect, maintain or promote their health status. For example, proper diet, and appropriate exercise are activities perceived to influence health status. Life style is closely associated with health behavior and factors influencing life style are socioeconomic, educational, and cultural.
Metabolic Syndrome X
A cluster of metabolic risk factors for CARDIOVASCULAR DISEASES and TYPE 2 DIABETES MELLITUS. The major components of metabolic syndrome X include excess ABDOMINAL FAT; atherogenic DYSLIPIDEMIA; HYPERTENSION; HYPERGLYCEMIA; INSULIN RESISTANCE; a proinflammatory state; and a prothrombotic (THROMBOSIS) state. (from AHA/NHLBI/ADA Conference Proceedings, Circulation 2004; 109:551-556)
Prescriptions, Non-Drug
Written directions for the preparation, administration, or application of a non-drug remedy. This includes prescriptions for corrective lenses, self-help and orthopedic devices, and physical therapy and rehabilitation measures.

Projektets delaktighet i utbildning

checked Avhandling


(Only selected options are displayed. Click here to display all options)

Registrering i andra projektdatabaser

Avhandlingens 4 delarbeten är registrerade i projektdatabas FoU Västra Göteland:
IDNR: 100521, 206152, 206261, 237142

2. Projektorganisation och finansiering

Arbetsplatser involverade i projektet

information Added workplaces
Regioner - Västra Götalandsregionen - Närhälsan - Vårdcentraler - Område V4 - Närhälsan Askim vårdcentral (Göteborg) workplace verified by Västra Götalandsregionen on 2018-02-27
Regioner - Västra Götalandsregionen - Närhälsan - Vårdcentraler - Område V4 - Närhälsan Frölunda vårdcentral (Göteborg) workplace verified by Västra Götalandsregionen on 2018-02-27
Regioner - Västra Götalandsregionen - Närhälsan - Vårdcentraler - Område V4 - Närhälsan Högsbo vårdcentral (Göteborg) workplace verified by Västra Götalandsregionen on 2018-02-27
Regioner - Västra Götalandsregionen - Närhälsan - Vårdcentraler - Område V4 - Närhälsan Opaltorget vårdcentral (Göteborg) workplace verified by Västra Götalandsregionen on 2018-02-27
Regioner - Västra Götalandsregionen - Närhälsan - Vårdcentraler - Område V4 - Närhälsan Styrsö vårdcentral workplace verified by Västra Götalandsregionen on 2018-02-27
Regioner - Västra Götalandsregionen - Närhälsan - Vårdcentraler - Område V5 - Närhälsan Gibraltargatan vårdcentral (Göteborg) workplace verified by Västra Götalandsregionen on 2018-02-27
Regioner - Västra Götalandsregionen - Närhälsan - Vårdcentraler - Område V5 - Närhälsan Kungshöjd vårdcentral (Göteborg) workplace verified by Västra Götalandsregionen on 2018-02-27
Regioner - Västra Götalandsregionen - Närhälsan - Vårdcentraler - Område V5 - Närhälsan Kungssten vårdcentral (Göteborg) workplace verified by Västra Götalandsregionen on 2018-02-27
Regioner - Västra Götalandsregionen - Närhälsan - Vårdcentraler - Område V5 - Närhälsan Majorna vårdcentral (Göteborg) workplace verified by Västra Götalandsregionen on 2018-02-27
Regioner - Västra Götalandsregionen - Närhälsan - Vårdcentraler - Område V5 - Närhälsan Masthugget vårdcentral (Göteborg) workplace verified by Västra Götalandsregionen on 2018-02-27
Regioner - Västra Götalandsregionen - Närhälsan - Vårdcentraler - Område V5 - Närhälsan Slottsskogen vårdcentral (Göteborg) workplace verified by Västra Götalandsregionen on 2018-02-27
Företag - Privata vårdgivande bolag - inom Västra Götalandsregionen - Vårdcentraler - Göteborg - Stiftelsen Carlanderska sjukhuset - Vårdcentralen Carlanderska workplace verified by Västra Götalandsregionen on 2018-02-27
Företag - Privata vårdgivande bolag - inom Västra Götalandsregionen - Vårdcentraler - Göteborg - Västerledens vårdcentral AB - Västerleden Vårdcentral och BVC - Frölunda Torg workplace verified by Västra Götalandsregionen on 2018-02-27
Företag - Privata vårdgivande bolag - inom Västra Götalandsregionen - Vårdcentraler - Göteborg - Capio Närsjukvård AB - Capio Vårdcentral Axess workplace verified by Västra Götalandsregionen on 2018-02-27
Företag - Privata vårdgivande bolag - inom Västra Götalandsregionen - Vårdcentraler - Göteborg - Praktikertjänst AB - JohannesVården - Vårdcentral och BVC workplace verified by Västra Götalandsregionen on 2018-02-27

Coworker

Camilla Bylin Ottehall
Fysioterapeut, FaR-teamet

Tutor

Maria Larsson
Leg. sjukgymnast, Närhälsan FoU-centrum Göteborg och Södra Bohuslän, Sektionen för hälsa och rehabilitering
Mats Börjesson
Överläkare/professor, Medicin, Geriatrik och Akutmottagning Östra, Institutionen för neurovetenskap och fysiologi
Lars Hagberg
Hälsoekonom, Universitetssjukvårdens forskningscentrum

Finansiering

Grants

FoU-rådet i Göteborg och södra Bohuslän (670931) the grant is verified by a Researchweb® grant provider
13 500 SEK
Stefan Lundqvist, Åsa Cider, Mats Börjesson, Maria Larsson, Lars Hagberg

2017, Physical Activity on Prescription (PAP), in Patients with Metabolic Risk Factors. A 6-month Follow-up Study in Primary Health Care.

3. Processen och projektets redovisning

Publikationer från detta projekt

Detaljerad projektbeskrivning

Background

There is strong evidence that inadequate physical activity (PA) is associated with increased risk of developing lifestyle-related diseases and premature death ( 1, 2). Metabolic syndrome (MetS) is not consistently defined, but includes overweight, abdominal obesity, insulin resistance, dyslipidaemia, and hypertension in various combinations ( 3). The presence of MetS carries a high risk for developing cardiovascular disease and type 2 diabetes ( 4).

PA – definition and health impact: The definition of PA is ”any bodily movement produced by skeletal muscles that results in energy expenditure” and can be categorized as e.g. a household, occupational, leisure time, and sporting activity ( 5). Exercise is PA with the objective to improve or maintain physical fitness components and is categorized in terms of the type, frequency, duration, intensity, and purpose ( 6-8). The internationally recommended minimum level of PA ( 9) is moderate-intensity aerobic PA 150 min per week or, alternatively, vigorous-intensity aerobic PA 75 min per week ( 10, 11), which has been associated with a clinically relevant risk reduction. A sufficiently high physical activity level has the possibility to affect all components in MetS ( 12, 13).

PA and PAP as a method of treatment: Despite the evidence-based positive effects of regular PA on health, implementing PA as an integrated method of treatment in health care remains a major challenge ( 14). The Swedish National Board of Health’s guidelines for disease prevention methods recommends the use of individual-based dialogue, written information, training diaries, a pedometer, and structured follow-up when the patient´s PA-level is insufficient ( 15). An example of such a treatment strategy is physical activity on prescription (PAP), which is individually tailored for each patient and prescribed for preventive and therapeutic purposes as a first-line treatment. PAP-treatment has been shown to increase the PA level in patients with metabolic risk factors visiting primary health care ( 12, 16). Meta-analyses of international PAP studies show varying results, when comparing increased PA levels with usual care and there is uncertainty due to the lack of high quality studies ( 17, 18). Swedish lifestyle interventions, including PA, has shown to be cost-effective ( 19, 20) and the Swedish PAP intervention method has positive effects on PA levels, body composition, cardio metabolic risk factors, and health related quality of life (HRQOL) ( 21, 22). Although scientific evidence has resulted in clinical treatment guidelines ( 15) and there are some evaluated Swedish PAP studies ( 21-24), PA is still underutilized as a treatment strategy in Swedish health care ( 25, 26). There is still a lack of knowledge about PAP interventions and further studies are needed evaluating clinical feasible PAP strategies on a large sample ( 27-29).

PAP-treatment and behaviour change: The PAP-treatment in Sweden is part of the patient-centred care ( 30, 31) and the patient-centred counselling approach of motivational interviewing (MI) is often used as a tool to motivate and encourage the patient to change PA behaviour ( 32). The PAP method is based on theory-based change models, primarily the transtheoretical model and social cognitive theory ( 33-35). However the reasons why PA interventions are effective are not fully understood ( 36) based on the factors that intervene between interventions and PA behaviour change ( 37). There is still uncertainty regarding the best methods of promoting PA and the factors affecting long-term adherence ( 36), correlated to improved effects on MetS parameters ( 38). To look at intervening causal variables – mediators (e.g. self-efficacy), has been a way of understanding possible correlates of PA in the pathway between an intervention and the outcome ( 39-41). The mediating variable model declare that changes in correlates of PA possibly lead to changes in physical activity ( 40, 42, 43). The literature concerning the role of correlates of PA change in experimental PA studies is, however, relatively elusive ( 43). More research is required about possible correlating factors and PA behaviour ( 38, 44).

In primary care in the city of Gothenburg, health care centers have implemented PAP-treatment, individualized for patients with metabolic risk factors, with the purpose of increasing the PA level and health benefits. This specific model of PAP-treatment in daily clinical work has not been evaluated.

Aims and objectives

The general aim of this thesis is to evaluate two different PAP-treatment strategies in order to increase the PA level of patients, physically inactive, with metabolic risk factors and to explore correlating factors possibly predicting response or non-response to increased PA level. In a health economics study, the cost-effectiveness of PAP with two different strategies will be evaluated.

Objectives

  • To explore the association between PAP-treatment and the PA level of patients with metabolic risk factors and the relationship between changes in the PA level and changes in metabolic risk factors and HRQOL at the 6-month follow-up (Study 1).
  • To explore factors associated with PA-level change in a 6-month period of PAP-treatment in order to highlight potential predicting correlates to increased PA-level. (Study 2).
  • To evaluate a one year enhanced support with physiotherapist for patients, non-responding to PAP-treatment at 6 months follow-up in a primary health care centre setting, regarding PA level, fitness, metabolic health effects and HRQOL (Study 3).
  • To evaluate cost-effectiveness of enhanced support from physiotherapist compared to PAP-treatment at the health care centre in a two years perspective (Study 4).

Clinical implication

This thesis will indicate how different PAP strategies in primary health care affects the level of PA, metabolic health and HRQOL for physically inactive patients with metabolic risk factors. Highlighting possible correlates of PA in an early stage give the opportunity to support the patient in the behavioural change process and individualize the PAP-treatment on an adequate degree to increase PA level. A health economic analysis will illuminate the cost-effectiveness of the PAP-treatment strategies.

Ethical aspects

The overall possible risks when intervening with physical activity are considered to be very small. The patient may experience some discomfort in exercising, a feeling considered to be a natural reaction initially. A certain discomfort can also be experienced in blood sampling. The patient got information about the possibility to receive treatment with PAP and to be included in the study by written information and orally by their caregiver. There are ethical approval for all studies.

Table 1. Overview of studies included

StudyAimStudy designParticipantsData collectionAnalysis
ITo explore the association between PAP-treatment and the PA level of patients with metabolic risk factors and the relationship between changes in the PA level and health outcomes, including metabolic risk factors and HRQOL at the 6-month follow-up.Prospective, longitudinal observational study.444 patients in primary care, aged 27-85 years (56% females), physically inactive, having at least one component of metabolic syndrome, and receiving PAP-treatment.

4 tests for self-assessed PA level (ACSM/AHA, IPAQ, SGPALS, and Frändin/Grimby). BMI, waist circumference. Blood pressure. Blood samples (FPG, TG, Chol, HDL, and LDL).

HRQOL SF-36. Frequency of visits at the health care center.

Parametric per-protocol analysis. Within group analysis – paired sample t-test or Wilcoxon sign-rank test, effect size Cohen´s d (d-value).

Between group analysis – independent sample t-test or Mann Whitney U-test.

Correlation analysis - Univariate multiple- and multivariate linear regression, MANOVA and Pillai´s trace.
IITo explore factors associated with PA-level change in a 6-month period of PAP-treatment in order to highlight potential predicting correlates to increased PA-level.Prospective, longitudinal observational study.See study ISelf-assessed PA-level (IPAQ). Questionnaire correlates of PA - Self-Efficacy (SEE), Outcome Expectations (OEE-2), Enjoyment (PACES), Social support (SSES), Readiness to change (VAS), HRQOL SF-36, and BMI.

Parametric statistics.

Within group analysis – paired sample t-test or Wilcoxon sign-rank test.

Correlation analysis – Spearman´s rank correlation and Univariate regression analysis, effect size r 2 (r 2-value).

Probability analysis – Chi-2 test for independence, correlation value phi (EMφ)EM·
IIITo evaluate whether an enhanced support with physiotherapist for patients not responding to PAP-treatment at 6 months follow-up in a primary health care centre setting influences PA level, fitness, metabolic health effects and HRQOL.

Randomized controlled trial.

1-year follow-up
188 patients non-responding to PAP-treatment initiated at health care center randomizes to either enhanced support by physiotherapist (Intervention) or continued ordinary PAP-treatment at the health care centre (Control).

PA level, anthropometric-, metabolic components and HRQOL as in study I.

Ergometer cycle test for the intervention group.

Intention to treat analysis.

Within group analysis – paired sample t-test or Wilcoxon sign-rank test, effect size Cohen´s d.

Between group analysis – independent sample t-test or Mann Whitney U-test.
IVTo evaluate cost-effectiveness of enhanced PAP-support from physiotherapists compared to usual care at the health care centre.Health economic, cost-effectiveness.See study IIIIntervention costs, healthcare consumption, absents from work, HRQOL SF-6D.In a cost-utility analysis, intervention costs is compared to changes in quality adjusted life years (QALY), healthcare consumption and absents from work for the two treatment alternatives.

Table 2. Overview of measurements.

PA level. The PA level was the primary outcome and four questionnaires were used due to the known complexity of PA assessments.
1. Self-assessment was according to the American College of Sports Medicine (ACSM) and American Heart Association (AHA) public health recommendations ( 45). The questionnaire was included in the working document during the time that new indicator questions regarding PA was evaluated and validated by the Swedish National Board of Health ( 46). The last seven days of PA were investigated and the patient responded to two PA questions (ACSM/AHA questionnaire), where 30 min of moderate-intensity PA per day resulted in 1 point and 20 min of more vigorous-intensity PA per day resulted in 1.7 point during each specific day of the week. A value of 5 points indicated an inadequate PA level. The vigorous-intensity question has been used in previous studies supporting the construct validity of the measure ( 47, 48).
2. International Physical Activity Questionnaire - Short Form (IPAQ), assessing the level of PA during the last 7 days ( 49). The IPAQ measures three specific types of PA: walking, moderate-intensity activities and vigorous-intensity activities in separate scores (duration in minutes and frequency in days). The scores are presented as median metabolic equivalent (MET)-minutes per week and a Total MET-minutes/week can be summarized. The IPAQ also calculate a categorical score (low-moderate-high) where the moderate level is corresponding to a PA level of at least 600 MET-minutes/week, a level equivalent to the international public health recommendation ( 9). The instrument is translated into Swedish and has acceptable test-retest reliability, concurrent validity and criterion validity for adults ( 49, 50).
3. The Saltin-Grimby Physical Activity Level Scale (SGPALS) assessed leisure time PA during the past year at four different levels, from sedentary/physically inactive to vigorous physically active ( 51). Validated against e.g. metabolic risk factors ( 52, 53) and the SGPALS has been published in an updated Swedish form ( 54).
4. A six-grade PA scale (Frändin/Grimby), was used and includes household activities ( 55). This scale correlates with physical performance and self-assessed fitness and is used to classify PA among the elderly ( 56).
Anthropometrics
Body weight was measured with light clothing and without shoes to the nearest 0.1 kg using an electric scale. Body height was measured in an upright position without shoes to the nearest 0.5 cm using a scale fixed to the wall, and the body mass index (BMI) was calculated. Waist circumference (WC), to the nearest 0.5 cm, was measured in a standing exhaled position, with a measuring-tape placed on the patient’s skin between the lower rib and the iliac crest.
Blood pressure
Systolic and diastolic blood pressure were measured in mmHg according to guidelines ( 57) after 5 min rest with the patient seated with a blood pressure sphygmomanometer attached to the right upper arm at the level of the heart.
Blood samples
Blood samples were used to measure (in mmol/l) fasting plasma glucose (FPG) after an overnight fast, triglycerides (TG), cholesterol (Chol), High Density Lipoprotein (HDL), and Low Density Lipoprotein (LDL). Values were analyzed according to the European Accreditation system ( 58).
Health related quality of life
The HRQOL was assessed with the Swedish version of the Short Form 36 (SF-36 Standard Swedish Version 1.0), which includes 36 questions ( 59). It generates eight health concepts: physical functioning (PF), role physical functioning (RP), bodily pain (BP), general health (GH), vitality (VT), social function (SF), role emotional functioning (RE), and mental health (MH). The health concepts were converted to 0-100 points, where higher values represented a better HRQOL. The different health concepts of the SF-36 were also grouped into a physical component summary (PCS) and mental component summary (MCS). The SF-36 has shown good to excellent internal consistency and reliability and was validated in a representative sample of the Swedish population ( 59).
Self-efficacy expectations
Self-efficacy expectations was measured with the Self-Efficacy for Exercise Scale (SEE) ( 60) focusing on the ability to exercise for 20 minutes, three times per week in the face of barriers to exercise. The questionnaire includes 9 items (e.g. The weather was bothering you, You had to exercise alone, You felt depressed), rated on an ordinal 10 point scale ranging from 1 (Not confident) to 10 (Very confident). The item scores are summarized and divided by the number of responses indicating the strenght of self-efficacy expectations. The SEE has been tested for older adults and older women post-hip fracture displaying high internal consistency, acceptable reliability measured with squared multiple correlation coefficients and sufficient to strong evidence for construct- and criterion validity ( 60-62).
Outcome expectations
Outcome expectations was assessed with the Outcome Expectations for Exercise-2 Scale (OEE-2) ( 63), a revised version from the original OEE scale concisting of 9 positive worded items ( 64) and developed to identify elderly individuals with low expectations for the effects of exercise. The OEE-2 questionnaire is a 13-item measure with 9 positive worded items (e.g. Helps me feel less tired) and 4 negatively worded items (e.g. Is something I avoid because it causes me to be short of breath) divided into two subscales: positive OEE and negative OEE. The items are rated on a 5 point Likert scale ranging from 1 (Strongly agree) to 5 (Strongly disagree). The negative OEE items are reversed scored and the numerical ratings for each response are summarized and divided by the number of items. The OEE-2 questionnaire was revised in year 2005 to include 4 items concerning negative expectations with exercise based on qualitative findings ( 65, 66) and has shown some evidence for convergent validity, internal consistency and person-, item reliability ( 63).
Enjoyment
Enjoyment was measured using the Physical Activity Enjoyment Scale (PACES) ( 67), modified by Motl et al. ( 68). The questionnaire consists of 16 items whereof 9 positively worded (e.g. I think it´s fun, It gives me energy, It is very pleasant) and 7 negatively worded (e.g. I feel bored, I don´t like it, It´s frustrating for me). Each item is rated on a 5 point Likert scale from 1 (Does not apply at all) to 5 (Truly applies), the negatively worded items are reversed scored and the responses are added to a score ranging from 16 to 80. . The PACES has been tested for 18-24 year old students and adults with functional limitations showing acceptable test-retest reliability, internal consistency and criterion validity correlated to physical function ( 67, 69). The modified PACES has shown satisfying factorial and construct validity for adolescent girls ( 68) and invariance for the factor structure, factor loadings and factor variances across time ( 70).
Social Support
Social support was assessed by using the Social support for exercise scale (SSES) ( 71) including 13 items, divided in a family and friends part and measured on a 5 point Likert scale. Eleven items are positively worded (participation and involvement) and two items negatively (rewards and punishments) describing social interactions possibly linked to exercise behaviour during the previous three months. Responses were ranged from 1 (none) to 5 (very often) and “not applicable” was given a score of 1. The item scores are summarized in three subgroups: Family support – positive, Friend support – positive and Family support – negative. The Friend support – negative subgroup scores were excluded by Sallis et al. because it did not emerge in the factor analysis. The SSES has shown acceptable test-retest reliability, high internal consistency and significant criterion validity correlated with a vigorous exercise measure ( 71).
Readiness to change
The readiness to change PA level was measured at baseline including three questions estimated on a 100 mm visual analogue scale (VAS): How prepared are you? How important is it for you? How confident are you to succeed (self-efficacy)? The VAS line is anchored in each ends with words describing the minimal respectively maximal extremes of the dimension being measured. The questions derives from MI and behaviour change counselling according to Rollninck et al ( 72, 73) where a higher value on the VAS indicates increased readiness to change. VAS has been used in the social and behavior sciences both as a research and clinical tool and is considered to have acceptable reliability and validity ( 74).
Sociodemographic factors
Age (years), sex (female-male), social situation (single-married/cohabit-other), economy (good-neither nor-bad), education (elementary grade-upper secondary school-university college) and smoking (yes/previously/no)EM were also measured.

Included studies

Study 1

Physical Activity on Prescription (PAP), in Patients with Metabolic Risk Factors.

A 6-month Follow-up Study in Primary Health Care.

Published: April 12, 2017STRONG 

Citation: Lundqvist S, Börjesson M, Larsson MEH, Hagberg L, Cider Å (2017) Physical Activity on Prescription (PAP), in patients with metabolic risk factors. A 6-month follow-up study in primary health care. PLoS ONE 12(4): e0175190.

https://doi.org/10.1371/journal.pone.0175190

Aim: The aim of this observational study was to explore the association between PAP-treatment and the PA level of patients with metabolic risk factors and the relationship between changes in the PA level and health outcomes, including metabolic risk factors and HRQOL at the 6-month follow-up.

Method: This study included 444 patients in primary care, aged 27-85 years (56% females), who were physically inactive with at least one component of metabolic syndrome. The patients were selected as a convenience sample from 15 primary health care centers in Gothenburg center/west. The PAP-treatment model included: individualized dialogue concerning PA, prescribed PA, and a structured follow-up. PA-level, Metabolic risk factors and HRQOL were measured at baseline and the 6-month follow-up of PAP-treatment.

Results: A total of 368 patients (83%) completed the 6 months of follow-up. Of these patients, 73% increased their PA level and 42% moved from an inadequate PA level to sufficient, according to public health recommendations. There were significant improvementsEM[ (p]≤ 0.05), with mainly small d-values, in the following metabolic risk factors: body mass index, waist circumference, systolic blood pressure, fasting plasma glucose, cholesterol, and low density lipoprotein. There were also significant improvements, with small d-values, regarding health-related quality of life, assessed by the Short Form 36, in: general health, vitality, social function, mental health, role limitation-physical/emotional, mental component summary, and physical component summary. Regression analysis showed a significant association between changes in the PA level and health outcomes. During the first 6-month period, the caregiver provided PAP support 1-2 times.

Conclusion: This study indicates that an individual-based model of PAP-treatment has the potential to change people’s PA behavior with improved metabolic risk factors and self-reported quality of life at the 6 month follow-up. Thus, PAP seems to be feasible in a clinical primary care practice, with minimum effort from healthcare professionals.

Ethical Approval: Regional Ethical Review Board in Gothenburg (Dnr: 678-14).

Study 2

Correlates of Physical Activity change in a 6-month Physical Activity on Prescription (PAP) Intervention on Patients with Metabolic Risk Factors.

Aim: The aim of this study was to explore baseline factors associated with PA-level change in a 6-month period of PAP-treatment in order to highlight potential predicting correlates to increased PA-level.

Method: The study population included the same 444 patients as in study one, 27-85 years, physically inactive, having at least one metabolic risk factor and receiving PAP-treatment, carried out as part of a daily clinical primary care practise.

Correlates of PA measured at baseline were: self-efficasy expectations, outcome expectations, enjoyment, social support, readiness to change, BMI and HRQOL. PA level was measured, using IPAQ, at baseline and 6-month follow-up.

A univariate regression analysis was used to explore the association between correlates of PA and PA-level and a Chi-square test for independence was used analysing possible predicting correlates to increased PA level at 6-months follow-up. Statistical significance was set at p ≤ 0.05.

Preliminary results: The follow-up group (n=368, 83%) were analyzed. The regression analysis displayed significant associations (p≤0.05), with small r 2-values (EM® 2=0.011 - 0.032), between PA level at 6-month and the following baseline correlates of PA: self-efficacy expectation, outcome expectation, readiness to change - confident, BMI and HRQOL - physical component summary. The analysis of dichotomized correlates of PA at baseline versus PA level at 6-month follow-up revealed a probability to increase PA-level and reach a moderate level of PA respectively with 1-4 positive valued correlates of PA. The correlation values for significant values were small (EMφ=-0.28 – 0.26).

Preliminary conclusion: The results indicate a possibility to find correlating factors of meaning for increased physical activity level at 6 month follow-up of PAP-treatment. Highlighting possible correlates of PA in an early stage give the opportunity to support the patient in the behavioural change process and individualize the PAP-treatment on an adequate degree to increase physical activity level.

Ethical Approval: Regional Ethical Review Board in Gothenburg (Dnr: 678-14).

Study 3

Physical activity on prescription with two different strategies. One year follow-up regarding physical activity level, metabolic health and health-related quality of life. A randomized controlled trial.

Aim: The aim is to evaluate whether an enhanced support with physiotherapist, for patients non-responding to PAP-treatment at 6 months follow-up in a primary health care centre setting, influences physical activity level, fitness, metabolic health effects and health-related quality of life.

Method: In this randomized controlled trial 188 patients, non-responding to PAP-treatment initiated at health care center randomizes to either enhanced support by physiotherapist (Intervention) or continued ordinary PAP-treatment at the health care centre (Control). The intervention by physiotherapist includes fitness test using a ergometer bicycle, motivative dialogue concerning physical activity, individually dosed physical activity regarding frequence, duration and intensity. The intervention also includes an uppdated PAP. The patient is supported by physiotherapist 7 times during the intervention time of 1 year.

The size of the study was calculated based on a power of 90%, to detect a difference of 20 % in physical activity level between the intervention (40% responders) and control (20% responders) groups referred to physical activity level ≥5 points, at a significance level of 0.05. Intention-to-treat analysis will be used. Data will be processed using Paired samples t-test or Wilcoxon sign-rank test based on data level in within group analyses. Analyzes between intervention and control group will be performed using Independent samples t-test or Mann Whitney U-test. Statistical significance is set at p ≤ 0.05.

Hypothesis: An enhanced support by physiotherapist gives room for enlarged effects on physical activity level with an opportunity to influence cardiorespiratory fitness, metabolic health and health related quality of life.

Clinical implication: An increased physical activity level in the non-responder group via an individually designed support by physiotherapist will increase the possibility to save time and resources for both the patients and health care system. Evaluating effects on cardiorespiratory fitness in addition to metabolic health and health related quality of life gives an immersed understanding of the health effects due to this intervention.

Ethical Approval: Regional Ethical Review Board in Gothenburg (Dnr: 529-09).

Study 4

Cost-effectiveness of physical activity on prescription with two different strategies.

Aim: Patients who are non-responders to PAP-treatment at 6-month follow-up can either get enhanced support from physiotherapists to become more physically active or continued ordinary PAP-treatment at the health care centre (usual care) for a period of two years. The aim is to evaluate cost-effectiveness of enhanced support from physiotherapists compared to usual care.

Method: 188 patients, non-responding to PAP-treatment are randomized to either enhanced support from physiotherapists or to usual care. Participants are followed up during two years with measurement of quality of life, healthcare consumption and absence from work. In a cost-utility analysis, intervention costs is compared to changes in quality adjusted life years (QALY), healthcare consumption and absence from work for the two treatment alternatives. Cost-effectiveness will be expressed in costs per gained QALY. The analysis will have a societal perspective, a time horizon of two years and be complemented will a sensitivity analysis.

Ethical Approval: Regional Ethical Review Board in Gothenburg (Dnr: 529-09).

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Att främja arbete med fysisk aktivitet hos patienter med metabola riskfaktorer i primärvård.
Fysisk aktivitet på recept som behandlingsmetod vid vårdcentral eller som förstärkt stöd av fysioterapeut., from FoU i Västra Götalandsregionen
http://www.researchweb.org/is/html/vgr/project/267981