Competing demands in primary care (context)

Barriers to promoting physical activity among UK general practitioners include a lack of time, competing clinical priorities, and limitations in resources and relevant education. For example, in a survey of 166 GPs, 65 GP registrars and 71 practice nurses, 91.2% of respondents described time as a factor limiting them in discussing physical activity with their patients.¹³⁸ Similarly, a survey of all 1228 GPs in Perth, Australia, WA, indicated that a lack of time was the most frequently cited barrier to the promotion of physical activity.¹³⁹ A qualitative focus group study in the USA explored perceptions of nurse practitioners regarding their role in physical activity and its promotion for older adults and concluded that nurse practitioners felt unable to give systematic attention to physical activity for older adults:

All of the nurse practitioner (NP) participants were clear that only a small percentage of a primary care healthcare visit for any adult client can be devoted to counselling regarding physical activity and exercise . . . NPs described other important issues that of necessity take priority in the primary healthcare visit . . .

Melillo et al.¹⁴⁰

Data from interview participants in our study provided further explanation about competing priorities:

When we have 10 minutes, we don’t have time to even do what we’re meant to be doing.

GP, interview participant 004

I think physical activity unfortunately does take a bit of a back step because it’s probably not seen as so important as referring somebody who is expected cancer or sorting somebody’s medications out.

GP, interview participant 001

It’s a recurring theme that there’s just not enough hours in the day to do everything, so you have to pick and choose what you think that patient is going to change.

Practice nurse, interview participant 003

Our work suggested that competing priorities in primary care also include different models of care. The primary care management of long-term conditions typically focuses on the diagnosis and categorisation of disease according to the International Classification of Diseases and Related Health Problems, Tenth Revision.⁶⁸ It emphasises the management of mediators such as blood pressure and glycaemic control in diabetes.¹⁴¹ The International Classification of Functioning, Disability and Health⁶⁹ provides an alternative perspective, which places more emphasis on functional limitations within a biopsychosocial context. It emphasises activity limitations and participation restrictions that include contextual, personal and environmental factors. In the context of the International Classification of Functioning, Disability and Health,⁶⁹ physical activity has the potential to promote more proactive, ‘whole-person’ and preventative care approaches, benefiting the patient and targeting health-care resources more effectively.^21,22 Primary care nurse practitioners have also expressed concerns that there is a focus on diagnosis as opposed to health promotion.¹⁴⁰ Data from interviews supported this view that health professional culture should focus more on preventative actions:

People can do a lot for themselves but there needs to be a change in the culture for health professionals. The medical model needs to become an upstream public health model and a rehabilitation and a social model.

Public contributor, long-term condition, interview participant 005

However, evidence suggests that this approach has time and resource implications for GPs, nurses and other primary care professionals, which can act as barriers to its implementation. For example, in a paper reporting a rehabilitation programme combining cognitive behavioural therapy principles and therapeutic exercise for the self-management of low back pain, professionals found it difficult to challenge the beliefs of patients, such as preferences for medication,¹³⁹ which led towards application of a biomedical approach, rather than a broader biopsychosocial approach.¹⁴² On the other hand, the American College of Sports Medicine established the ‘Exercise is Medicine’ campaign in 2007, which aims to facilitate improved health and well-being through regular exercise prescription from primary care health professionals. They promote the idea that physical activity and exercise are ‘medicine’ and that health-care providers should and will ask about, and recommend, physical activity and exercise.⁶⁷

Aligning practice culture with physical literacy (mechanism)

Physical literacy is defined as ‘the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life’.¹⁴³ (Reproduced with permission from the International Physical Literacy Association, May 2021.) Thus, if practice culture is aligned with the elements of physical literacy, then this could stimulate and augment physical activity promotion. Aligning a practice culture with the elements of physical literacy would involve influencing the beliefs, attitudes, values and behavioural norms within a practice (i.e. ‘how things get done).¹⁴⁴

The promotion of physical literacy is emerging as a promising strategy to increase lifelong physical activity participation in younger age groups of the population, but there is less evidence for physical literacy in the context of supporting older adults with long-term conditions to achieve physical activity guidelines. However, an iterative, mixed-methods, consensus development process in Canada produced a model of physical literacy for adults aged ≥ 65 years.¹⁴⁵ This model proposes the promotion of physical literacy to facilitate successful and sustained increase in physical activity participation by older adults.¹⁴⁵

In one of our theory-refining stakeholder interviews, the teaching and learning of physical literacy was discussed, alongside how a culture of physical literacy might be promoted:

The only thing that we can aspire to is actually create a culture in which the environment and the educator has such knowledge and practice that physical literacy becomes nurtured, over a considerable period of time.

Researcher, pedagogy, interview participant 007

An important initiative aiming to enhance physical activity promotion across the primary care setting is the Active Practice Charter from the Royal College of General Practitioners. The vision behind this initiative is that, despite having a crucial role, GPs and their teams have not felt empowered, and lack the skills, to encourage physical activity in their practice or the local community (see also Context–mechanism–outcome statement 4: improving capability of practice workforce). The criteria for becoming an ‘active practice’ have been left intentionally broad and undefined, and emphasise that the practice team and their patients will have the best idea of what will work for them. Practices are encouraged to consider changes that will reduce sedentary behaviour, encourage partnership with local physical activity providers, and increase physical activity in staff as well as patients. Indeed, evidence shows that health professionals who are more physically active are more likely to encourage their patients to be physically active and provide better counselling and motivation of their patients to adopt such health advice.^146,147 The initiative also provides some ideas for implementation, including walking to the waiting room to call patients in, providing standing space in the waiting room with information for patients explaining why, improving cycle facilities, signposting to local fitness opportunities and signing up to be a parkrun practice. The practice ‘lead’ could be a GP, a practice nurse, a social prescriber or the patient participation group. The initiative is designed to celebrate and inspire GP surgeries to take steps to increase physical activity and reduce sedentary behaviour in their patients and staff.¹⁴⁸ This initiative promotes the elements of physical literacy by enhancing motivation through celebration of a new ‘Active Practice’ status, confidence by offering achievable, realistic suggestions of ways to develop an ‘Active Practice’, and physical competence, knowledge and understanding through the provision of information and resources to facilitate ‘Active Practice’ activities.

The ‘Moving Healthcare Professionals Programme’¹³⁴ and ‘Moving Medicine’¹³⁵ are two further examples of initiatives designed to support health professionals working in primary care to promote physical activity. These programmes have not yet been evaluated.

Consistent messaging that aligns with the principles of physical literacy is also evident in relevant guidelines. For example, NICE guidance emphasises the lifelong value of physical activity, recommending that campaigns should provide messages that sustained ill health in old age is not inevitable,⁷⁵ thus contributing to increased alignment across the practice and more widely.

Promoting physical activity as part of routine practice (outcome)

Evidence indicates that interventions promoting physical activity are more likely to be effective when integrated into routine care.^63,149 NICE recommends that all health-care practitioners and policy-makers view the encouragement of physical activity as a part of routine practice, to take place at every opportunity.^75,150,151 This integration into routine practice is more likely to happen if practice culture is aligned with the elements of physical literacy. For example, the ‘Let’s Get Moving’ (LGM) physical activity pathway is a UK-based attempt at embedding physical activity promotion into routine primary care and was recommended by Public Health England for commissioning at a local level by primary care trusts within NHS England.¹²⁹ It combines several methods of supporting behavioural change including brief interventions, motivational interviewing, goal-setting, providing written resources and follow-up support. A feasibility study conducted in 14 London surgeries showed that 75% of the patients who attended the follow-up consultation had increased their physical activity level, and almost all patients (97%) participated in one of the physical activity options. Of note, patients were identified either opportunistically or through electronic disease registers. Opportunistic intervention reached only 6% of patients, whereas recruitment using disease registers ranged from 9% to 59%, indicating that this method of embedding routine physical activity promotion may be more effective. Moreover, although disease register screening was more costly (£191 per patient) than opportunistic recruitment (£53 per patient), these additional costs also came with a higher completion rate and better outcomes in terms of self-reported behavioural change in patients completing the care pathway.^127,128 Practices that recruited via disease registers were also able to book longer consultations to accommodate the care pathway steps and components.¹²⁶ This suggests that increased alignment with physical literacy (e.g. the practice taking specific steps to take responsibility for physical activity by adopting a disease register approach) could have increased the promotion of physical activity as routine.

Although encouraging, it is important to note that only a small number of practices who were supportive and motivated towards physical activity took part¹²⁶ and the evaluation relied on self-reported physical activity, which is prone to recall and response bias.¹⁵² The LGM programme was also less successful when rolled out to other locations. In Gloucestershire, it did not work well alongside existing established local exercise referral schemes. The programme flow chart was viewed as too complicated and lacked the simplicity needed to align it with other programmes. There needed to be more investment in improving the visibility of LGM to ensure understanding of its role and purpose and for it to become successfully embedded over time into local routine health services. Recommendations for improvement included establishing a steering group to assist with co-ordination, wider consultation, improved alignment with current programmes, and streamlining paperwork to alleviate the challenge of delivering the intervention in a time- and resource-constrained setting.¹³⁰ Similarly, although the LGM pathway was accepted as a clinically feasible resource for primary care physiotherapists, it did require modifications and the support of additional resources.¹³¹ Therefore, taking steps to align a practice with the elements of physical literacy may only work to increase routine physical activity promotion if the programme itself is aligned with existing systems.

When improving alignment of the practice with physical literacy, our work suggests that care also needs to be taken so that routine, embedded physical activity promotion does not become burdensome. For example, one participant explained the benefits of electronic systems designed to facilitate conversations about physical activity:

Templates are quite useful because they do prompt you to ask the question.

Practice nurse, interview participant 006

In contrast, one of the GPs interviewed explained how such tasks could be unhelpful:

But, would I want any more forms to fill in or boxes to tick or guidance that says, ‘If you can touch your toes and tie up your shoelaces without getting breathless you score a 1’ . . . it wouldn’t help me at all.

GP, interview participant 004

Similarly, NICE has acknowledged the competing demands on primary care practitioners’ time during patient appointments. NICE recommends that practitioners deliver very brief informal advice repeatedly, if this fits better with the time available.¹⁵⁰ Although brief interventions can increase self-reported physical activity in the short-term, there is insufficient evidence of their long-term impact, the impact that they have on objectively measured physical activity and factors influencing effectiveness, feasibility and acceptability.¹¹⁸

Overall, the evidence suggests that in order to encourage the promotion of physical activity ‘as routine’, protocols, pathways and procedures are insufficient; an inherent belief in the value of physical activity or ‘physical literacy’ needs nurturing across the practice team. Some strategies appear to promote increased alignment of people, settings and systems to create an environment that promotes physical literacy. However, there also needs to be sufficient scope in a practice context for people to work in a biopsychosocial way, adopt a functional approach and promote physical activity to people with long-term conditions.

Inconsistent and unco-ordinated physical activity promotion (context)

Despite a rise in primary care physical activity initiatives and research,¹⁵³ physical activity promotion in primary care remains inconsistent. For example, an online survey of 1013 self-selecting UK GPs found that the conditions for which GPs indicated that they would discuss and recommend physical activity varied from 78% for people who were overweight to 43% for asthma and 15% for cancer. There was a lack of skills, knowledge and confidence relating to the guidelines with only 20% of responders expressing that they were ‘broadly’ or ‘very familiar’ with the national physical activity guidelines, with over half reporting not having had any form of training.¹⁵⁴ Similarly, a cross-sectional study of 1937 patients in Germany were asked whether or not their GP had advised them about regular physical activity in the preceding 12 months. Only 33% stated that they had been advised to be more physically active, and those more likely to receive GP advice on physical activity were men; those suffering from specific long-term conditions such as pain, coronary heart disease, diabetes mellitus or arthritis; those taking more than five medications; and younger age groups.¹⁵⁵ In Australia, only 18% of patients (n = 1799) reported receiving a physical activity recommendation from their GP in the past 12 months, although other developed countries had higher percentages such as the USA (32%) and Canada (42%).¹⁵⁶ From a GP’s perspective, 95.5% (127/223) of GP survey respondents in Denmark reported giving advice on physical activity at least weekly,¹⁵⁷ and over half of GPs in the USA reported discussing physical activity with most of their at-risk patients.¹⁵⁸ In a scoping review determining the extent to which GPs record information about physical activity in medical records, there was a large variation in the recording of advice on physical activity, ranging from 1% to 78.8%.¹⁵⁹

In the UK, primary care health professionals can refer patients with long-term conditions to exercise referral schemes, consisting of an initial assessment, a tailored programme of exercise and professional supervision.¹⁶⁰ Compared with usual care, they have shown a small effect in increasing the proportion of individuals achieving 90–150 minutes of at least moderate-intensity exercise per week.¹²² However, these are often not implemented as intended, with low referral rates, and poor rates of attendance and completion.^65,161 Barriers to referral include geographic isolation, uncertainty about patient selection criteria, medicolegal responsibilities and a lack of feedback about patients’ progress.¹⁶² In another focus group study, participants reported that it was not easy to access the scheme as it was poorly advertised by primary care staff. Very few participants had been referred to the scheme as a result of a GP or nurse making a recommendation and were more likely to have been informed about the scheme from others and then have requested a referral from staff themselves.¹⁶³

One participant in our theory-building workshops talked about her experiences of the exercise referral scheme, also highlighting a lack of co-ordination:

There’s the exercise referral scheme but we don’t refer a huge number to it because it is there and then it disappears due to short-term funding, or the criteria change and then you have to get a new form, with a paper pad that has to be signed by different people, everything else is online so it’s a bit of a palaver and puts barriers in place whereas it should be quite easy to do.

GP, interview participant 004

Awareness of alternative community initiatives can also be inconsistent and unco-ordinated. Out of a representative random sample of 800 Dutch general practitioners, less than one-fifth were involved in any kind of formal collaboration network with other health-care professionals and physical activity providers.¹⁶⁴ However, GPs who did participate in a formal alliance more often referred patients from their practice to a local fitness centre or sports facility. Furthermore, these GPs were more positive about the physical activity facilities in their area, indicating that this kind of co-ordination is valuable.

Finally, it is suggested that in order to develop and sustain consistency and co-ordination of physical activity promotion, synergy of all the relevant stakeholders is needed (e.g. government, civil society, private sector, non-governmental organisations and sport bodies) and should be implemented at all levels of physical activity promotion, including international, national, local and within the primary care teams.¹⁵³

Allocation of resources (mechanism)

To reduce the burden on GPs, many studies have identified alternative professionals to deliver physical activity advice. For example, interventions have involved practice nurses;^165–170 health-care assistants;¹⁷¹ expert patients;¹⁷² physical activity ‘coaches’, ‘counsellors’ or ‘facilitators’;^173–176 exercise professionals;¹⁷⁷ physiotherapists;^178,179 accredited exercise physiologists;¹⁸⁰ or combinations of allied health professionals.^21,181 The idea is that these professionals are trained to deliver relevant physical activity advice and work with patients on specific goals, meaning that GPs can concentrate on other tasks and, consequently, enabling physical activity promotion to be delivered more consistently because specific resources (i.e. time, money and expertise) have been allocated for this purpose. To be effective, these professionals should be appropriately trained, appropriately resourced and the physical activity intervention should be aligned to condition management pathways.¹⁵³ However, there is a risk that delegating this task to other health professionals would mean that GPs do not feel responsible for this activity.

A randomised controlled trial of such an intervention has provided evidence of effectiveness and cost-effectiveness. In total, 203 Australian primary care patients were referred from general practice to exercise physiologists who provided face-to-face coaching and telephone coaching over 12 weeks. The primary outcome was step count, recorded for 7 days on a pedometer. Coaching achieved a modest increase in activity equivalent to 10 minutes of walking per day, at a cost of AU$245 (< £150) per person. The authors concluded that the persistence of increased activity at 9 months after the end of coaching suggests that this is a good value health intervention.¹²⁴ Australia is already in a unique position as the only country that provides some federal government sponsored reimbursement for exercise physiology consultations. Therefore, advice and referral to accredited exercise professionals can assist in promoting physical activity and exercise, reducing physical inactivity and, hence, potentially, alleviating some of the burden of chronic disease.⁶⁷ Although an increase from 0.38 to 1.44 referrals per 1000 encounters was shown over a 7-year study period, 2009–16, GP referral rate to exercise physiologists was low, suggesting that education about the role of exercise physiologists is needed.¹⁸⁵

An emerging type of intervention, involving ‘Care Sport Connectors’ (health-care or community-based exercise professionals) who connect primary care to the sport and recreation sector, is being tested in the Netherlands.¹²³ Patients are referred to these ‘connectors’ who help them be more physically active, by explaining the benefits and normalising physical activity as a behaviour rather than as a therapy. They guide patients towards local physical activity opportunities in the patients’ locality, at a time suited to them, thus reducing the burden on pressurised health services.¹⁵³ It is important to acknowledge, however, that surgeries staffed largely by GPs without much role substitution from nurses and other allied health professionals may have less flexibility to accommodate physical activity counselling.¹²⁸ As previously described, the LGM pilot study demonstrated that allocating resources to the identification of patients through electronic disease registers can improve the reach and effectiveness of physical activity interventions compared with opportunistic recruitment because this method enabled longer appointments to be made in advance and may have reduced selection bias on behalf of professionals.¹²⁸ The Exercise as a Vital Sign programme also enabled rapid, structured data collection by medical assistants through an electronic medical record system. Prior to the physician entering the room, medical assistants asked patients two questions: (1) ‘How many days a week do you engage in moderate to strenuous exercise (like a brisk walk)?’ (2) ‘On average, how many minutes per day do you exercise at this level?’.¹⁸⁶ The idea is that collecting this ‘vital sign’ data acts to increase physician and patient awareness of inadequate physical activity, thus acting as a ‘red flag’ helping to trigger a broad range of health-related, preventative actions, such as lifestyle counselling and referrals. These actions would then bring about increased physical activity, weight loss and improved glycaemic control among patients with inadequately controlled diabetes.¹⁸⁶

Finally, NHS general medical practices between 2014 and 2015 were provided with financial incentives to assess physical activity levels in people with hypertension using the General Practice Physical Activity Questionnaire (GPPAQ). However, it is not known whether or not this approach resulted in an increase in physical activity levels in this group as it was discontinued after 1 year.¹⁵⁴

Improved opportunities to change behaviour (outcome)

If physical activity promotion becomes more consistently co-ordinated in primary care through the allocation of resources, then evidence suggests that there will be improved opportunities for people with long-term conditions to change their behaviour.

The Exercise as a Vital Sign programme was designed to increase consistency and co-ordination of physical activity promotion through ascertainment and recording of patients’ self-reported physical activity by a medical assistant as part of an initial visit to primary care. The programme improved exercise-related clinical care processes (increased progress note documentation, exercise counselling and lifestyle-related referrals) and provided clinical benefit (e.g. weight loss among overweight/obese patients and improved glycaemic control among patients with diabetes), thus improving opportunities for behaviour change. This supports a model in which the identification and initial discussion of exercise can be increased by the systematic collection of patient-reported exercise data as part of usual clinical workflow. However, it is important to note that the clinical improvement was relatively small, suggesting that this approach needs to be linked to more intensive and effective tools to help patients increase their physical activity. Indeed, information-only interventions seldom have a clinically significant impact if not linked to effective means for patients or providers to act on the information provided.¹⁸⁶

The LGM evaluation¹²⁸ found that identifying patients using electronic records was more effective than opportunistic identification, with the completer rate being 27% compared with 16%, respectively. This method of patient identification has been used previously in primary care-based health behaviour interventions. This is probably because the method removes the potential for selection bias that might be introduced when GPs or practice staff make subjective decisions about which people to promote physical activity to, and also does not rely on busy GPs or practice staff to remember to recruit patients.¹⁸⁷

In a systematic review,¹⁸⁸ barriers to and facilitators of social prescribing were related to the implementation approach, legal agreements, leadership, management and organisation, staff turnover, staff engagement, relationships and communication between partners and stakeholders, characteristics of general practices, and the local infrastructure.

Despite limited evidence for the success or value for money, the use of non-medical referral, community referral or ‘social prescribing’ interventions have been proposed as a cost-effective alternative to help those with long-term conditions manage their illness and improve health and well-being.^182,183 Social prescribing includes but is not specific to physical activity promotion; however, the associated evidence is relevant because it involves a specific professional making referrals to community-based initiatives.¹⁸⁴

Other means of providing physical activity advice include online^121,189,190 or telephone counselling,^119,191,192 to improve opportunities for physical activity promotion. In one study, telephone counsellors with degrees in public health, health promotion or allied health sciences were trained to provide a patient-centred, motivational interviewing intervention. Maintenance outcomes for the 12-month telephone-delivered intervention for physical activity and dietary behaviour change demonstrated that the intervention was effective in promoting sustained behaviour change following a 6-month period of no intervention contact.^193,194 However, in 201 people with back pain, acceptance of face-to-face contact has been shown to be higher than with online or web-based coaching, indicating that integrating some element of actual contact is important to consider.¹⁹⁵

In conclusion, our work suggests that if primary care can consistently identify and advise patients about insufficient physical activity during their primary care consultations and link them to a robust referral system of physical activity opportunities, then this could improve opportunities for physical activity promotion.

Varying access to resources and varying individual characteristics (context)

Evidence suggests that individuals are on a spectrum of physical functioning and this can affect how people access or receive physical activity promotion. At one end of the spectrum are those who are healthy, active and mobile and who can organise their everyday lives independently, pursue their interests and are integrated into social networks. This group most often receives physical activity promotion through public health or through group interventions in fitness or community centres and would benefit from sustaining physical activity. At the other end of the spectrum is a group of chronically ill, immobile or frail older individuals who have already lost their independence and live in special residences or nursing homes. This group would most likely be approached by going into their residences and recruiting them for on-site exercise (group) interventions and therapy. Older people between those two extremes are often sedentary, with one or more long-term conditions and mobility restrictions, but still live in their own homes. This group are at high risk of losing their independence and have a lot to gain from increasing physical activity, but are difficult to reach for physical activity interventions.^{59,155,196,197} This varying context of people living with long-term conditions is important to consider when designing ways of delivering physical activity promotion through primary care. For example, some patients may require one-to-one support and supervision to start and continue physical activity, whereas some patients require less direct input and would be able to self-select and self-monitor appropriate activities if given the opportunity. Similarly, in a survey of GPs, the most important barrier to referring patients to local exercise activities was their patients limited financial possibilities (46%) and restricted knowledge of local exercise or sport facilities (19%).¹⁶⁴

People with long-term conditions can also be at varying stages in the behaviour change process. According to the transtheoretical model (stages of change theory), a specific health behaviour develops and progresses, ideally but not inevitably, through five stages. These stages can be used to describe readiness to become and stay physically active and include (1) precontemplation, (2) contemplation, (3) preparation, (4) action and (5) maintenance.^198,199 For example, the Physician-based Assessment and Counselling for Exercise (PACE) intervention for people with type 2 diabetes aimed to change physical activity behaviour by applying this theory. However, a possible reason for the lack of effectiveness of the PACE intervention was that most intervention providers did not tailor their counselling to individual stages of change but instead discussed the same topics with all patients.^200,201

One participant interviewed as part of the current study corroborated this idea, stating that interventions would be less likely to succeed with ‘precontemplators’ as they are not yet considering change:

There’s no point in people starting to dictate to people if they’re not on board with it.

Public contributor, long-term condition, interview participant 005

The NICE guidance also highlights the importance of recognising times when people may be more open to change, such as when recovering from a related condition (e.g. following diagnosis of cardiovascular disease), as well as recognising when offering a behaviour change intervention may not be appropriate owing to personal circumstances.²⁰²

Improving relevance of advice through adaptation (mechanism)

All relevant guidelines emphasise how physical activity interventions should be tailored for individuals and relevant in terms of an individual’s motivations and goals; current level of activity and ability; circumstances, preferences and barriers to being physically active; and health status (e.g. whether they have a medical condition or a disability). In particular, NICE guidance for exercise referral schemes recommend that policy-makers and commissioners should fund exercise referral schemes only if the scheme incorporates the core techniques of behaviour change, recognises when people are open to change, agrees goals and develops action plans, advises on and arranges social support, tailors behaviour change techniques to the individual, monitors progress, develops coping plans to prevent relapse, and collects data on the programme and participants. Furthermore, NICE recommends that when delivering brief advice, it is important to tailor it for people with a range of abilities, preferences and needs.^64,150 Advice should also be tailored to the availability of local resources and possibilities.

In addition, GPs have expressed dissatisfaction that patients do not act on advice about increasing physical activity levels and feel that a different approach is needed to effectively communicate information that is more amenable to patients’ personal situations.¹³⁶

This was further explained by one of the GPs interviewed:

It’s about taking a patient and establishing what they can do currently and then building from that . . . giving realistic scenarios of what they can do which is tailored to their ability and uses what is in community already.

GP, interview participant 001

Many studies and interventions have done this by linking into existing programmes or community initiatives,^{168,192,203–206} thus making physical activity opportunities more relevant and accessible in an individual’s local environment. The LGM initiative involved signposting patients to local physical activity opportunities including local authority leisure services, private clubs, sports and dance, pedometer schemes, outdoor activities and exercise referral schemes.¹²⁸ Furthermore, a 12-week primary care physical activity programme in Spain linked people with long-term conditions to local resources, encouraged social support and also included a visit with all participants to the nearest community resources (e.g. sport facilities). This was a place where regular physical activity could be continued and participants were offered a special monthly rate, thus reducing barriers associated with cost and resource availability. Increases in self-reported physical activity were sustainable over a 15-month period.²⁰⁷ In a realist review of social prescribing, it suggested that patients are also more likely to engage if the activity is accessible and transit to the first session is supported.¹⁸⁴

A survey of 340 Dutch GPs found that 49% felt that giving a specific and directed recommendation was more effective in stimulating patients to start physical activity than giving open-ended advice.¹⁶⁴ Furthermore, people with chronic obstructive pulmonary disease have described pursuing physical activity because of personal interests, values and pleasure.²⁰⁸

When asked about how best to adapt physical activity advice, one participant interviewed as part the current study said:

Asking them what they would like to do, rather than telling them to do something. What would you like to be able to do in your life that you are not able to do at the moment, and do you think you might be able to do it if you worked at it?

Public contributor, long-term condition, interview participant 002

Similarly, a practice nurse interviewed as part of the current study explained that they focused discussions on meaningful, personalised and achievable goals:

I try to set achievable goals . . . you have to know your patient well to set goals.

Practice nurse, interview participant 003

Research indicates that it is also important that physical activity interventions are adapted in terms of the amount of challenge given to participants. For example, in a qualitative study of older adults with and without cognitive impairment, healthy control participants placed more importance on interesting, challenging, and enjoyable physical activities whereas people with cognitive impairment emphasised the theme of ‘simple/light/safe exercise’.²⁰⁹ Moreover, falls prevention programmes that are considered too demanding by the participants can have a negative impact on quality of life,²¹⁰ with other researchers observing patterns in study attrition where participants with the worst function withdrew from the rehabilitation group (perhaps because it was too difficult) and those with better function withdrew from the control group (perhaps because it was too easy).²¹¹ This suggests that a lack of tailoring can negatively affect the effectiveness of physical activity interventions, whereas incorporating individualised, relevant and tailored advice has the potential to maximise the relevance and effectiveness of advice.

Self-management and educational programmes, where there is increased patient involvement in long-term condition management, have a key role.^212,213 For example, a behaviour change counselling protocol was delivered by practice nurses, named the Self-management Support Programme, and involved consultations based on the ‘five As’ cycle counselling technique (assess–advise–agree–assist –arrange). The trial showed improvements in physical activity in people with long-term conditions, but also that the intervention was more effective with an accompanying, personalised monitoring and feedback tool suggesting that techniques to enable monitoring and feedback is an important element in promoting sustained behaviour change.^167,170

Finally, considering the impact of support networks that can act as barriers to or facilitators of physical activity is also shown to be an important part of promoting physical activity and physical function for people with long-term conditions. In many studies, participants were encouraged to use a variety of supports including family and friends, their health-care team and community supports (e.g. walking groups) identified from a community reference guide compiled at study outset.^187,193,194 Guidance from the USA²¹⁴ also explains how participation in physical activity in a community setting with others, such as friends and family, can increase physical activity levels. Buddy systems, contracts with others to complete specified levels of physical activity, and walking groups are recommended ways to provide individuals with friendship and support for physical activity.²¹⁴ Furthermore, one-to-one sessions can be helpful to enable initial tailoring and review, whereas group-based activities can offer another source of immediate motivation, other than anticipated health benefits. As discussed by Fife-Schaw et al.:¹⁷⁷ ‘The challenge is to associate exercise with other affective responses such as those resulting from success or socialising – hence an interest in linking activity to sport rather than repetitive activity on gym equipment’.¹⁷⁷ Group consultations for people with long-term conditions have shown positive effects on lifestyle, indicating significant potential for delivering system-wide benefits when resources are limited,²¹⁵ and have started to gain traction in Australia and America, with examples also in the UK for diabetes care.²¹⁶

Barriers to physical activity that are relevant to support networks include an overprotective family member or the need to care for a family member.²⁰⁸ One of the people with a long-term condition interviewed as part of this study also explained the different ways in which family support systems can work:

Some families may not be good for increasing PA [physical activity] as have a restricted view of the world, but walking with a friend and talking, you don’t notice the extreme pain. Some families are very supportive and can be very important for changing attitude but sometimes you need to go outside to find a support system for your activities.

Public contributor, long-term condition, interview participant 005

Sustained improvement in physical activity (outcome)

Many studies have described ‘tailoring’ of an intervention but have in fact chosen from a range of standardised protocols. However, in a randomised controlled trial of primary pare patients with musculoskeletal pain, tailoring an exercise intervention to patients’ highest-valued daily activity goals (e.g. ability to walk to the shop) resulted in improvements in pain, functioning and physical performance.^217,218 Furthermore, in a study of behaviour change counselling by Australian Accredited Exercise Physiologists (AEPs),¹⁸⁰ flexible behaviour change counselling, based on the professional judgement of the AEP, and the preferences of the participant, resulted in improved physical activity levels in participants.

As living with a long-term condition can be unpredictable in nature, the ability to provide adaptable physical activity advice is important to promote sustained improvements in physical activity. Incorporating the ability to make adjustments to changes in individual needs over time means that interventions are more effective when compared with treatment solely tailored to predefined characteristics of a particular long-term condition.^217,218 Moreover, in the interviews conducted by Holden et al.,²¹⁹ the complexity of exercise behaviour was highlighted, showing that physical activity can fluctuate over time in response to numerous barriers and facilitators. In the light of this, several studies have incorporated relapse prevention elements.^{168,169,171,220–222}

Another important strategy highlighted by patients as way of increasing physical activity is establishing a habitual behaviour.²⁰⁸ An example of this is ‘Join2move’, which is a successful web-based self-paced physical activity programme in which the patient’s favourite recreational activity was gradually increased in a time-contingent way. The programme sought to align with the day-to-day activities of people by including common activities (e.g. walking, cycling) that are easy to integrate into their daily routine.²²³ Being able to retain independence and take part in activities that a person enjoys doing, has been shown to be important. For example, canine-based interventions and community-based football schemes appear to be effective in helping to initiate and sustain physical activity for people with long-term conditions.^224,225 Therefore, linking improvements in physical activity with personally relevant improvements in physical function may influence reasoning for being more physically active across the lifespan. A qualitative study including primary care patients with chronic obstructive pulmonary disease identified that believing that physical activity can positively affect chronic obstructive pulmonary disease can be a motivational factor.²⁰⁸ Similarly, as part of a randomised controlled trial involving a physical therapist-guided aerobic exercise intervention for people with depression, 13 trial participants took part in semistructured interviews. In this group, movement could be categorised into four aspects: (1) movement as an absolute value, (2) movement as a personal value, (3) movement as a means and (4) movement as a sensation in body and mind. They connected their emerging categories ‘struggling toward your healthy self’ and ‘challenging the resistance’ to the aspect ‘movement as a means’ and ‘movement as a personal value,’ in terms of feeling proud and more like oneself again and by enhancing participation and ability.²²⁶ Finally, in a mixed-methods review of exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis, it was concluded that people exercised regularly if they perceived exercise to be important, fun and enjoyable. However, if the benefits derived from exercise were not considered a ‘good return’ for the time and effort people invested, exercise was not sustained.²²⁷

Taken together, our work suggests that physical activity promotion needs to consider the characteristics of the individual and their personal priorities, as well as the resources they have (or do not have) available to them and how these might change. Furthermore, doing so means that advice would be more personally relevant and improving physical activity is more likely to be sustainable.

Lack of confidence and knowledge among practice staff (context)

Primary care is an ideal setting for physical activity promotion for people with long-term conditions because of its familiarity to patients who are used to attending for appointments, established trust and rapport, and the ability to assess eligibility.^196,228 Although the general medical practice venue has many advantages, the effectiveness of GP, nurse and other primary care staff counselling on physical activity is hindered by barriers, including a lack of educational resources for primary care professionals, a lack of formal clinician training for physical activity counselling and time constraints.¹³¹ As previously mentioned, in an online questionnaire-based survey of self-selecting GPs in England, only 20% of responders were broadly or very familiar with the national physical activity guidelines, 26% were not familiar with any physical activity assessment tools and 55% reported that they had not undertaken any training with respect to encouraging physical activity.¹⁵⁴ Furthermore, in a qualitative study 12 in-depth semistructured interviews of nurses in Dutch general practices involved in diabetes care reported a deficiency in their lifestyle counselling skills. The nurses explained that they did not know how to develop a structured action plan in co-operation with the patient and the difficulties in adapting their counselling to the patient’s stage of change. The nurses expressed the wish to develop skills to overcome this barrier; for example, ‘Sometimes I supply information too fast. The patients are in an earlier stage of change’.²²⁹

In a study examining the knowledge and practice of GPs (n = 342) and primary care physiotherapists (n = 89), more physiotherapists (50.5%) than GPs (28%) correctly reported the minimal physical activity guidelines. However, with the exception of overweight patients, GPs were more likely than physiotherapists to promote physical activity to patients with known cardiovascular risk factors, such as hypertension, suggesting that there is scope to improve knowledge.²³⁰ In a recent study, two practice nurses and six health-care assistants delivered a theory-based walking intervention to 63 patients in their primary care practices. Although the intervention was mostly delivered as planned, motivational components aimed at improving self-efficacy were not.¹²⁵

Prescribing medication is considered a more attractive and effective option than promoting physical activity, with lifestyle behaviour change considered to be the most difficult part of diabetes management, with advice limited to providing specific, standardised suggestions such as walking for 30 minutes three times per week.^136,142

There also appears to be a lack of confidence, knowledge and understanding in the perceived roles and responsibilities associated with physical activity promotion. For example, in a qualitative systematic review of the barriers to effective management of type 2 diabetes in primary care, it emerged that, despite continuing policy drives to promote self-management, clinicians often find it hard to share responsibility effectively with patients to support behaviour change. Changing role boundaries, between primary and secondary care, and also between physicians and nurses within primary care, have generated uncertainty and unease about where clinical responsibility resides.²³¹ Similarly, in a survey exploring views about collaboration between GPs and exercise providers in the promotion of physical activity, half of the GPs thought that they had an important role in stimulating physical activity, while the other half considered their role present but ‘limited’.¹⁶⁴ On the other hand, in a process evaluation exploring the adoption and implementation of physical activity and dietary counselling by community health centre professionals (GPs, nurses and nurse practitioners, physician assistants), lifestyle counselling was rated as an important activity that they ‘should do’. This suggests that health professionals may be responsive to providing lifestyle counselling if it is brief, easy to implement (CMO statements 1 and 2), and if they can be trained at their convenience.¹⁶⁵

Improving sense of capability (mechanism)

When there is a lack of knowledge, skills or confidence, training, evidence suggests that it is important to encourage a sense of capability (or ‘self-efficacy’) among health professionals to promote physical activity. Indeed, patient behaviour change is probably related to GPs’ ‘professional self-efficacy’ to deliver an intervention.²³² However, recent surveys have highlighted the very limited medical curriculum time dedicated to physical activity and health, leaving professionals feeling insufficiently equipped to provide support or information to their patients.^233–236 In response, studies have developed interventions to address this need and improve capability among a variety of primary care professionals.

‘Movement as Medicine’ for type 2 diabetes represents an evidence-informed multifaceted behavioural intervention targeting physical activity for the management of type 2 diabetes.¹³⁶ It was co-developed for delivery in primary care. The exploratory work highlighted a need to focus on training provision for health-care professionals to equip them with the knowledge and skills to target the physical activity behaviour of their patients. Barriers to the acceptability and feasibility of the intervention were associated with six theoretical domains from the theoretical domains framework (TDF). These barriers and elements identified as having a positive influence are shown in Box 5.

An online, modular training programme has been developed in accordance with GPs’ stated preference for flexibility in completion and is currently undergoing evaluation in a pilot randomised controlled trial.¹³⁶

The ‘Moving Healthcare Professionals Programme’ model is a partnership between Public Health England and Sport England which provides educational resources about physical activity promotion. The interventions are designed to ‘spiral through’ existing educational approaches rather than be additional special study modules or ‘bolt-on’ courses, thus reducing self-selection bias in completion. The programme has delivered face-to-face training to 17,105 health-care professionals, embedded materials in almost three-quarters of English medical schools and overseen > 95,000 e-learning modules completed over 2.5 years. Evaluation of individual elements of the model is ongoing and aims to focus on the impact it has on the confidence and capability to provide brief advice. The model is designed to take a whole educational system approach to embed physical activity into clinical practice, including integration in undergraduate education as well as develop the capability of qualified health-care practitioners. This programme is supported by a consistent public health awareness campaign reiterating the importance of physical activity advice from clinicians. The model is designed to eventually become redundant as a result of taking a ‘whole educational life’ approach, and as the clinical social norm shifts towards the routine integration of brief physical activity advice into daily clinical practice¹³⁴ (see also Context–mechanism–outcome statement 1: changing practice culture through alignment).

One of the GPs interviewed as part of our study explained how knowledge and confidence might be influencing health professionals when talking to people with different long-term conditions about the benefits of physical activity:

It comes probably down to the knowledge and the confidence of the practitioner sat in front of the patient about how comfortable they feel about advising patients about physical activity with their conditions.

GP, interview participant 001

The ‘Exercise Is Medicine’ campaign established by the American College of Sports Medicine also aims to embed more information regarding the benefits of exercise through health professional training and continuing education programmes for primary care doctors and nurses.⁶⁷

Improved engagement of staff in physical activity promotion (outcome)

Effective physical activity promotion in health-care settings relies on professionals having the appropriate level of knowledge and skills to assess, counsel and support their patients.¹⁵³ Evidence suggests that an improved sense of capability helps improve engagement with physical activity promotion among primary care health professionals. For example, in comparison to GPs, who felt that their knowledge was inadequate, those who felt that they had adequate exercise knowledge were more likely to ask (72% vs. 49%) and counsel about exercise (48% vs. 29%).²³⁷ Other health-care professionals, such as physiotherapists, nurses or pharmacists, are also able to counsel patients to be more active; however, they too are in need of training in physical activity-related counselling.¹⁵³

A Canadian study promoting the importance of physical function as a ‘vital sign’ developed professional skills in functional goal-setting through (1) workshops, (2) a problem-based learning module, (3) case reviews of selected patients participating in the study and (4) development of a flow sheet for monitoring changes in physical functioning to be used within a patient’s electronic medical record. Although there was no significant change in the amount or type of information relating to physical functioning that were documented in patients’ medical records, primary care professionals reported an increase in the level of patients’ physical activity, improved goal-setting and problem-solving, and greater focus in their interactions. However, professionals felt that their own efforts at integrating the self-management aspects of care could be improved, with the main barrier being a lack of time to address the multiple concerns that patients with chronic conditions face, meaning that self-management goals were often given a lower priority²¹ (see also Context–mechanism–outcome statement 1: changing practice culture through alignment).

It is suggested that a lack of education on this topic will limit health-care professionals from encouraging physical activity, reducing their personal confidence to deliver advice, lowering their perceptions of benefit, and adversely affecting public health and commissioning decisions.²³⁸ Training health professionals to improve their knowledge about physical activity for people with long-term conditions, alongside how to apply effective behaviour change techniques, should improve their confidence and help them engage with physical activity promotion activities. However, evaluations of the current initiatives that are designed to enhance education and training for primary care health professionals and thus evidence to support this is currently limited.

Credible programmes (context)

Established programmes that take place in hospitals or leisure centres, and are delivered by qualified personnel (e.g. cardiac rehabilitation or exercise referral schemes), often have a high degree of inherent credibility due to their association with the health service, relevant regulatory bodies (e.g. the Register of Exercise Professionals) and inclusion as part of NICE guidance.⁶⁴ Furthermore, GPs often have established long-lasting, trusting relationships with their patients.^196,239 In Australian primary care, patients have been referred from general practice to receive physical activity coaching by exercise physiologists. The strategy is chosen because it is felt that a recommendation from a known and trusted GP would increase the uptake of coaching.¹²⁴

One of the patients in the current study also explained the credibility associated with recommendation from a GP:

Not everyone will want to take part but often they’ll listen to a doctor whereas they wouldn’t listen to anyone else.

Public contributor, long-term condition, interview participant 002

Similar views were captured in a qualitative exploration of facilitators of and barriers to active lifestyles among adults with osteoarthritis: ‘If my doctor tells me to [exercise], then I will’.²⁴⁰

However, as discussed previously, it is likely to be unfeasible for a GP to deliver and follow-up more complex physical activity advice and, therefore, further elements of credibility are drawn upon. For example, a mixed-methods review reflected how information about exercise for people with osteoarthritis is viewed as valuable if it comes from someone who is considered to be a knowledgeable health-care professional, who can explain why a person should do something, tailors the advice, clearly specifies what (or what not) to do and explains the benefits of adhering to the advice.²²⁷ Credibility can also be achieved by including peer-led elements. In line with Bandura’s social cognitive theory,²⁴¹ if a person with a long-term condition sees someone similar to them following treatment and lifestyle advice (e.g. improved physical activity), their own self-efficacy to change their lifestyle can increase.¹⁷² Moreover, leaders who are themselves patients with long-term conditions, or have close personal experience of a long-term condition, show greater empathy and tend to suggest more appropriate and realistic options than health professionals. Gamboa Moreno et al.^212,213 studied the impact of a self-care education programme on patients with type 2 diabetes in primary care. The programme was led by two leaders, one of whom either had a long-term condition or was a carer for someone who had. The other leader, who was a doctor or nurse, introduced themselves as a programme leader, rather than as a health professional, with the aim of strengthening the idea of peer education and support. Although this intervention did not show significant improvements in clinical outcomes for type 2 diabetes, self-efficacy improved significantly.

Intervention safety and effectiveness is also an important element of credibility for professionals and patients. In a home-based exercise intervention that was supported by primary care for older adults with long-term conditions and limited mobility (the HOMEfit randomised controlled trial), the authors concluded that it may have been ineffective due to the limited degree of supervision and less social interaction associated with a home-based intervention. There were also a high number of adverse events meaning that there were periods of restricted or suspended participation.²⁴² Similarly, one participant interviewed as part of this study described the need to know that a programme is safe:

They have to have their safeguards in place because the last thing they want is to push somebody to do something and then something happens.

Practice nurse, interview participant 003

When allocating physical activity promotion to other professionals, studies have ensured appropriate levels of training to improve credibility. For example, telephone counsellors in the study by Eakin et al.¹⁹⁴ had at least bachelor’s-level training in nutrition and dietetics, received intensive training in study protocols and motivational interviewing using a detailed training manual. This intervention led to modest but significant improvements in physical activity at 24 months for people with type 2 diabetes.

Increased trust and confidence in the programme (mechanism) leads to greater engagement (outcome)

Our work suggests that both professionals and patients need to develop trust and confidence in the programme to engage. An example of where a programme has not worked because of a lack of credibility among professionals is ‘Physical Activity on Prescription (PAP)’. The intervention was designed to increase physical activity among patients with a sedentary lifestyle but was used only occasionally by GPs in Sweden. In a qualitative study designed to explore and understand GPs’ perspectives of the scheme, it emerged that, whereas pharmaceutical treatment is used in the first instance and has good support, the PAP has low status and is regarded with distrust as some doctors feel the method lacks credibility and significance for the patient. Even though the GPs interviewed were convinced that physical activity was an important factor in preventing and treating illness, many were doubtful that a prescription can make a difference and were sceptical about the existing evidence for PAP and had doubts about the long-term effect.²⁴³ The method was viewed as an attempt at a simple solution to a complex lifestyle problem, or as one GP stated in a focus group as part of Persson et al.’s²⁴³ qualitative study:

We know that physical activity is good but I’m not sure that a slip of paper is enough.

Persson et al.²⁴³

Similar findings have been shown in a UK pilot trial of the Physical Activity Clinical Advice Pad, where use of the pads reduced over time, with data suggesting that the decline could be explained by health professionals not seeing its value.²⁴⁴ Therefore, it appears that professional acceptance and widespread implementation is more likely if an intervention is accompanied by an evaluation that determines its effectiveness and benefit.¹⁵³

In order to engage, evidence suggests that it is also important for professionals to feel that the intervention is reliable. For example, when exploring professional views of the National Exercise Referral Scheme it was concluded that a ‘lack of information about patient’s eligibility criteria or the nature of the intervention; long delays by the leisure centres in contacting, assessing and accepting the participants into the scheme; cumbersome paper work; and lack of feedback about patients’ progress as major factors that negatively affected their engagement with the scheme’.¹⁶² One of the practice nurses interviewed in this study stated: ‘I do not know what happened to the patients once we referred . . . I just tend not to refer any more . . .’.¹⁶²

Finally, credibility has been shown to be an important factor in increasing patient engagement. In a mixed-methods review of exercise interventions and patients’ beliefs for people with hip, knee or hip and knee osteoarthritis, health-care professionals were viewed as an important source of information, advice, reassurance and motivation. Clear instructions and advice from a trusted health-care professional were important in allaying people’s fears and anxieties about exercise, and convincing them that exercise is safe and beneficial, with the provision of good advice and information having a positive influence on people’s attitudes and behaviours towards exercise and its benefits.²²⁷ Feedback from professional focus groups about the physical activity advice pads suggested that tailoring advice to local opportunities added value for patients (see also Context–mechanism–outcome statement 2: providing resources); however, this was not built into the design of the intervention, which perhaps discouraged use by health professionals.²⁴⁴ Evidence from the social prescribing literature¹⁸⁴ suggests that adherence to activity programmes can be affected by having an activity leader who is skilled and knowledgeable, or through changes in the patient’s conditions or symptoms. Moreover, in a realist review exploring what is known about whether different methods of social prescribing referral do (or do not) work, it was suggested that people with long-term conditions are more likely to engage if they believe that the social prescription will be of benefit, the referral is presented in an acceptable way that matches their needs and expectations, and concerns are elicited and addressed appropriately by the referrer.¹⁸⁴

Further qualities and communication skills that people appreciate and derive value from include understanding, tolerance, taking a genuine interest, encouragement and support.²²⁷ Furthermore, research suggests that active health professionals are more likely to provide better, more credible, and motivating advice to their patients.¹⁴⁶

The characteristics needed to develop trust and confidence were also highlighted by people with long-term conditions interviewed as part of this study:

They’d need to be welcoming. They’d need the right attitude. Happy disposition, I think . . . somebody who is friendly towards you and listens to what you’ve got to say and doesn’t disregard what you’ve said.

Public contributor, long-term condition, interview participant 002

Someone who is really qualified, got a good track record. They do assessments . . . part of the assessment is talking to people for a while, not just 5 minutes and that’s it.

Public contributor, long-term condition, interview participant 005

In summary, our work suggests that programme credibility is important to encourage both patient and professional engagement in a physical activity intervention. The right professional with the appropriate skills and resources, delivering an intervention proven to be successful, and endorsed by patient groups and a GP, seems to be the most effective.

Box 1: resources for practice

Phase 3: bottom-layer materials

Document 2: activity cards

These demonstrate a series of activities suggested by the participants in the co-design workshops. In this iteration they are represented as card-based resources. These could be used in a variety of settings, such as coffee breaks and team meetings, and include:

a.

Conversation cards

These cue cards are designed to help reception staff initiate conversations with patients. This is to act as a kind of primer before the GP starts to raise these questions in the consultations.

b.

Case study cards

A selection of real-life stories from patients and health-care professionals of the whole-body benefits of physical activity. To be read, shared and discussed as a group during a coffee break or team meeting.

c.

‘Why don’t you?’ cards

A reflective activity where staff can address why they may not currently recommend physical activity to patients and as a group acknowledge and resolve the reasons behind these decisions.

Document 3: non-prescription pads

Non-prescription pads are tools that help to communicate why a person has not received treatment in the form of medication, as might be expected. This method could be employed in this case, where physical activity would be recommended but not necessarily ‘prescribed’ in the traditional sense. An existing example is the non-prescription for ‘get well soon – without antibiotics’ that can be seen at www.wales.nhs.uk/sitesplus/866/page/75953 (accessed 13 March 2020). Figure 19 shows a prototype ‘non-prescription’ pad for physical activity.

FIGURE 19

Design image of a ‘non-prescription’ pad for physical activity.

Evidence from the literature and from health professionals who have used physical activity prescriptions suggest that they have not worked in the past because a slip of paper is not seen as credible. However, it is proposed that this element would not be seen (or used) in isolation and would fit into the whole range of changes of culture, practice and behaviour for both patients and primary care professionals, giving it greater credibility.

Document 4: active practice poster and resources

This poster captures suggestions from co-design participants to make the GP practice more ‘activity friendly’ (Figure 20). Presented in the form of a blueprint, it provides inspiration and practical advice for creating more awareness and opportunity to engage in physical activity. The bottom half of the poster provides space to map out how a practice’s own space could be improved. Stationery would be provided to facilitate this.

FIGURE 20

Design image detailing resources to facilitate the development of an ‘activity friendly’ practice.

Document 5: marketing campaign

To help communicate a clear and consistent message across all GP surgeries, as well as more widely, our co-design work suggests a marketing campaign relevant to the benefits of physical activity. We have not developed the content for this yet but would take inspiration from the bold and creative campaign recently launched called ‘HELP US HELP YOU’ (www.adsoftheworld.com/media/print/nhs_take_the_drama_out_of_minor_illnesses; accessed 12 March 2020). Working with a marketing company alongside designers and artists, provocative and eye-catching posters and films have been created, encouraging people to change their behaviour and see a pharmacist rather than their GP. These posters cut through the traditional formality of marketing material found in GP surgeries and it would be worth considering the value of these in terms of effectiveness. The digital files for this campaign would be included in the box on a Universal Serial Bus (USB) or available to download through the online portal described in Function First online. These could then be displayed on screens or monitors already installed in waiting rooms.

Box 2: resources for one-to-one/group consultations

Phase 3: bottom-layer materials

These materials include:

a.

Multipurpose game boards

A supporting feature to help facilitate different activities with the same set of cards. The actual content of these could be refined and developed during future co-production sessions (Figure 21).

FIGURE 21

Design image showing details of guided card games.

b.

Adding more utility/dimension to the cards

It could be useful to arrange cards on a tabletop or gameboard. The cards could be given even more utility if there was a way to elevate or prioritise cards. Conversely, it may also be desirable to hide or discard cards from view (Figure 22).

FIGURE 22

Design image showing the multipurpose gameboards, methods of displaying cards and the resulting self-prescription.

c.

Self-prescription

This ‘self-prescription’ could be the take-away result of the card-game. Reflections and goals can be distilled into this simple folding card. This would act as a visual reminder of the goals set during the workshop and could be referred to during follow-up consultations (Figure 22).