NHSU CHAINs Learning & Sharing Event on Obesity 17 th February 2005 Exercise on Prescription Miranda Thurston Centre for Public Health Research University College Chester

Objectives The Exercise on Prescription model. Exercise on prescription: What can we learn from evaluation? EoP: an effective tool for the management of obesity? ‘Good practice’ in EoP?

The Exercise on Prescription Model The original model A primary care intervention making use of local community based leisure facilities, which provide structured and supported exercise programmes, to which general practitioners and sometimes other health professionals can refer their patients. One of the first schemes to emerge was the Oasis Scheme in East Sussex in the early 1980s.

The development of the traditional EoP model Variations on a theme ….green gyms, integrated into healthy living centres ….. Number of schemes ….. possibly 1000 in England (Riddoch, 2002) up from 200 reported in 1997 (Fox) but also proliferated globally (NZ, USA, for example). Key objective: behaviour change, specifically, to encourage long term adherence to exercise, amongst those who have disengaged from being physically active.

Exercise on Prescription: what can we learn from evaluation? Problems with methodology and little long term follow up (Iliffe et al, 1994). The changing focus of evaluation ….. Evidence of impact: physical and physiological outcomes measured objectively. Evidence of impact: social and psychological outcomes measured objectively (for example using the SF36). Attendance, attrition rates and adherence. Qualitative work with attenders and non-attenders to explore perceptions of the scheme and reasons for (non)attendance. Views of health professionals of the scheme.

Key messages from evaluation Those who are most at risk are least likely to adhere (Taylor, Doust and Webborn, 1998). Evidence of small but positive effects, particularly in relation to social and psychological variables (Riddoch, 1998), particularly for those who attended 75% or more sessions (Jones et al, 2001). Not necessarily effective in relation to increasing long term physical activity (Riddoch, 1998; Lawler and Hanratty, 2001; Stahl et al, 2002), the critical indicator of success. Those referred generally held positive views about exercise and its benefits but were concerned about whether they would enjoy it and how painful it would be (Jones et al, 2001). Self-reported changes in lifestyle and improvements in perceptions of health for attenders (Jones et al, 2001). Those who completed 75% or more sessions were most likely to have sustained the changes at 12 months but getting started was reported as ‘hard’. (Jones et al, 2001).

Understanding attrition rates 50% of patients who are referred fail to start an EoP scheme (Jones and Harris, 1998 cited in Chambers et al, 2000). Of those who start, only about 70% are still attending at 3 months (Fox et al, 1997) and 20% at 6 months (Smith and Iliffe, 1997, cited in Chambers, 2000). Figures for adherence levels range from 15-70% of individuals completing at least 75% of a 10 or 12 week programme (Shakey, 1997). Percentage of non-attenders highest for those who were referred for overweight (Jones et al, 2001).

Understanding attrition rates The factors that influence attendance on the scheme are likely to be similar to those that influence physical activity behaviour once the intervention is over. Those who had a partner were significantly more likely to complete more sessions than those who did not (Jones, Thurston, Kirby, 2001). Attenders commented on the social aspects of the programme (Jones et al, 2001; Baker, 2000); Hope et al, 1999; Lord and Green, 1995). Non-attenders report experiencing health problems which prevent them from going to sessions (Jones et al, 2001). Those who had been referred for being overweight reported finding exercise very hard and had difficulty keeping up with others (Jones et al, 2001). Older people were often worried about exercising (Jones et al, 2001).

EoP: an effective tool for the management of obesity? Health professionals reluctant to raise weight issues with patients (DoH, 2004); fewer overweight people referred to scheme than some other categories (Jones et al, 2001). GPs positive about the psychosocial aspects of EoP but sceptical about the medical impact (Jones et al, 2001). Overweight and obese patients lack confidence about their physical abilities, have low self-esteem, may feel humiliated in social settings, particularly where there is an expectation that they are required to ‘perform’ (DoH, 2004). Flexibility, tailoring interests to activities, skills and capabilities, accommodating group preferences, using activities that can easily be incorporated into everyday life are likely to increase participation in physical activity (Roberts, 1999). Bind people into social networks where physical activity is customary (Roberts and Brodie, 1992). Enjoyment, satisfaction, social interaction, learning skills ……… (Thurston and Green, 2004).

Good practice in EoP…..? How can we devise schemes and strategies that bind people into satisfying physical activities? What is the role of primary care in such strategies? Who are the key professionals? What skills and capabilities are required?