Evaluating provision of PA advice in primary care

Evaluating provision of PA advice in primary care BACR annual conference, Oct 2009 Professor Jim Mc. Kenna j. mckenna@leedsmet. ac. uk

Seven tenets of behaviour change ŒAcquiring new (and re-acquiring old) behaviours is a process not an event. ŒIt often requires learning through sequences (or approximations to ‘real life’) JACKSON (1997) H. Educ. Res. 143 -150

Seven tenets of behaviour change Psychological factors (notably beliefs and values) influence how people behave JACKSON (1997) H. Educ. Res. 143 -150

Seven tenets of behaviour change Ž The more beneficial and rewarding the experience the more likely that it will be repeated. Ž The more punishing and unpleasant the less likely that it will be repeated. JACKSON (1997) H. Educ. Res. 143 -150

Seven tenets of behaviour change Behavioural experience can influence individuals’ expectancies and values Individuals are NOT passive responders; they are proactive in behaviour change JACKSON (1997) H. Educ. Res. 143 -150

Seven tenets of behaviour change ‘ Social relationships and social norms have a substantial influence on how people behave JACKSON (1997) H. Educ. Res. 143 -150

Seven tenets of behaviour change ’ Behaviour in NOT independent of the context in which it is undertaken. ’ People influence, and are influenced by, their social environment. JACKSON (1997) H. Educ. Res. 143 -150

Rationale for PA promotion in General Practice • • Over 20 major diseases where PA is helpful (Lynch 2002) STRRIDE (RCT evidence); inactivity shows within 6 months An ‘idealised’ settings for prevention Wide access - 9 in 10 adults registered; attend at least once within 3 years; average consults/yr 4 (m) 5 (f) Staff have unique influence Patients are uniquely responsive Repeated and sequential opportunities New opportunities using Referrals and different PA messages BUT……

Preferred sources of support to start being active; Inactive respondents (by age groups) None Video Telephone Mail Medical advice Help kit Group Book Booth et al. , (1997) Preventive Medicine, 26, 131 -137 p 135

PACE Project Percentage of subjects who moved from Contemplator to Action stage of change during the study Calfas et. al. (1996) Prev Med, 25, 225 -33

PACE Project Caltrac accelerometer scores at baseline and follow-up (n=56) Activity counts per hour worn (P<0. 05) 60. 3 vs 83. 3 63. 3 vs 57. 4 . Calfas et al. , (1996) Prev Med, 25, 225 -33

It ‘works’ with adolescents • Spanish ‘adolescents’ (12 -21 years!, n=448) showed encouraging responses to focused PA promotion in General Practice • 41. 5% were more active (3+ days/week, 30 mins(+), moderate to vigorous) than controls at 6 -months – National estimates: 26% (5 -15), 17% (16 -24 year-olds) • NNT: 7 (for 6 month effect), 6 (for 1 year effect) Ortega-Sanchez R. et al. , (2004) Preventive Medicine, 38, 219 -26.

2008 RCT (USA): Christioan et al. , Arch Intern Med, 168, 141 -46 ‘…. In the intervention group, recommended levels of PA increased from 26%. . . to 53% at 12 months (P<0. 001), compared with controls (30% to 37%)…’

Pinto et al. , (2005) Am J Prev Med, 29, 247 -55. Objective activity monitoring also showed significantly increased PA among extended-advice versus brief advice participants at 3 months +50. 79 [minutes/week] vs 11. 11 and 6 months +42. 39 [minutes/week] vs 24. 18

Eden et al, (2002) Ann Intern Med, 137, 208 -15 Evidence is inconclusive…

2002 (Netherlands): Pat Educ Couns, 48 131 -7. Low levels of performance were found for …. . physical exercise for patients with hypertension … Discussion on compliance with therapy in case of angina pectoris… peripheral artery disease also showed a considerable gap between recommended and actual care ‘Inconclusive’ issue: Patient status (even when their clinical needs are PA-responsive) adds uncertainty

We know that GPs CAN effectively promote PA So why is the evidence ‘inconclusive? Profound influence of diverse powerful, subjective factors, including the strength of the treating physician's recommendation (Jackie Taylor spoke of ‘referral failure’)

2003 (USA) Am J Pub Health 93, 635 -41: ‘Inconclusive’ issue: Competition with other preventive options

Flocke et al. , (2006) Am J Prev Med, 30, 243 -51 Post intervention higher discussion rates for diet (25. 7% vs 20. 2%), exercise (27. 8% vs 16. 9%)…. No changes in patient motivation to improve behaviour ‘Inconclusive’ issue: Intervention does not shift behaviour

Adding to ‘inconclusivity’ • • Doctors (often) question their role in H-P Few ‘real’ chances to discuss health Not obliged to promote PA Doctors have to initiate most (60%+) PA discussions • European Action on Secondary and Primary Prevention by Intervention to Reduce Events !!! (EUROASPIRE !!!): neither clinicians nor patients pay sufficient attention to lifestyle risk factors, including PA; only 23. 9% of patients reported following specific advice from a health or exercise professional after their coronary event. – Patient self-report; moderate (16. 4%) and intensive (13. 4%) PA Kotseva et al. (2009) Eur. J. Cardiovasc. Prev. Rehabil. 16, 121– 37

Adding to ‘inconclusivity’ • GPs prefer to initiate discussion through ‘Illness’ • ‘Illness’ dominates the tone and content of discussions. It limits what can be said (Nordby, 2004) • Illness is transitory; unlikely to sustain PA • ‘Illness’ may not motivate PA in many (esp. young) people

Inconclusivity issue: What to encourage? Recession; mental health is THE driver of economic wealth Douglas et al. , (2006) BMC Pub H, 6, 136

Finland (2006): Hirvensalo et al. , Prev Med, 41, 342 -7. 34% recalled PA advice, 34% did not Recalling warnings AGAINST PA was more common among those having heart conditions. Recall was lowest among sedentary, those with fewest health problems, or those with no mobility issues. ‘Inconclusive’ issue: Patient recall varies

Women in Norway 2009: Werner and Materud. Soc Sci Med. The ‘hard work’ of not appearing too strong or too weak, too healthy or too sick, too smart or too disarranged Inconclusivity issue: patient consultation behaviour

Adding to ‘inconclusivity’: Access • ‘Unchangeingness’ of male body 15 -35 may limit ‘selfsurveillance’ • This may contribute to reputation for being ‘hard-toreach’ (why not ‘unreached’? ) • How to follow-up people who are residentially /domestically unstable?

What effects CAN result from an average of just 45 seconds spent discussing PA in consultations? OBJECTIVE Systematic and effective PA promotion Low counseling self-efficacy (What to encourage, How to do it? Lack of +/- feedback) Lack of training (PA or behav change) Lack of time Poor reimbursement (in consultations) Patient implication? (Lack of/ Concern to maintain positivity in) Patient relationship Diagnostics is more satisfying and rewarding Prioritisation of clinical reasons for visit ‘Rule of rescue’ PA attitudes and personal behaviour

Step % accurately estimated Odds Ratio 95% CI Own activity stage of change Step 1 86. 5% 4. 77 1. 48 to 15. 35 Consultation time (1 -4) Step 2 87. 3% 1. 61 1. 02 to 1. 62 Lack of success (1 -5) Step 3 88. 1% . 66 0. 16 to 1. 17 . 77 0. 46 to 1. 42 1. 02 0. 55 to 1. 93 Variable Lack of time (1 -5) Lack of resources (1 -5) Mc. Kenna et al. , (1998). BJSM 32, 242 -7.

Boorman report (2009) PA among NHS staff 18 22 21 10 13 5 9 So, 71% (18 + 22 + 21 +10) of NHS staff are ‘under-active’?

Conclusion Even though the data are inconclusive yet emerging …live with that, keep doing the good work you’re doing, help someone else to do the same and do it with them