Physical activity referral schemes: adherence and physical activity behaviour change

345 Pages·2015·6.22 MB·English

by  Clarke K

This work has been submitted to NECTAR, the Northampton Electronic
R
Collection of Theses and Research.
Thesis A
Title: Physical activity referral schemes: adherence and physical activity
behaviour change T
Creator: Clarke, K.
C
Example citation: Clarke, K. (2013) Physical activity referral schemes:
adherence and physical aEctivity behaviour change. Doctoral thesis. The University
of Northampton.
Version: AcceNpted version
http://nectar.northampton.ac.uk/7483/
Physical Activity Referral
Schemes: Adherence and Physical
Activity Behaviour Change
Submitted for the Degree of Doctor of Philosophy
University of Northampton
2013
Kerry Michelle Clarke
© Kerry M Clarke 18th December 2013
This thesis is copyright material and no quotation from it may be published without
proper acknowledgement.
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Abstract
It is well known that engaging in physical activity (PA) reduces the risk of developing
non-communicable diseases and improves general health. However, at the time of
this research, less than half of the UK population met the recommended levels of PA
(DH, 2010). Physical activity referral schemes (PARS) are one of the interventions
available in primary care (NICE, 2006a) for disease prevention and health
improvement, despite a high dropout rate (Gidlow, 2005) and unknown long-term
effectiveness (Pavey et al., 2011). The main aim of the four studies presented in this
thesis was to explore the adherence and behaviour change towards PARS in
Northamptonshire. The first study measured the long-term change in PA levels after
participation in Activity on Referral (AOR). The key outcome was a significant
increase in self-reported long-term PA levels (mean difference 1000 MET
minutes/week) for 105 adhering participants from a total of 2228 participants. One
in every 21 referred individuals self-reported an increase in PA at 12 months. To
explore the high levels of non-adherence, an interpretative phenomenological
analysis (IPA; Smith, 1996) was conducted with seven non-adhering AOR
participants. The findings showed that being listened to at the point of referral, a
range of positive experiences during the induction, alternative opportunities to
increase activity, and potential to re-engage in PARS were some of the factors that
enhanced adherence. Even though currently the key behaviour change measure for
a PA intervention is an increase in PA, there is no gold standard self-reporting PA
measure. Therefore, the third study was a comparison that tested the applicability of
the new General Practice Physical Activity Questionnaire (GPPAQ) and the
internationally validated International Physical Activity Questionnaire (IPAQ). The
GPPAQ is recommended to be used as a screening tool by health professionals for
the latest PARS called Let‟s Get Moving (LGM). There was a significantly weak
association between IPAQ and GPPAQ. Hence, the GPPAQ is only recommended to be
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used as a PA screening tool and not for evaluating PA levels for PARS research
studies. The final study was based on the new LGM physical activity care pathway
which included a brief intervention using Motivational Interviewing (MI), a
communication style that elicits the individuals‟ ambivalence regarding PA. Eight out
of 21 participants self-reported a PA increase at 6 months and the MI used during
the PARS was coded at beginner level. The two PARS included in this thesis were
compared for adherence; LGM adherence was 65% compared to 23% AOR
adherence at 3 months. In conclusion, this research has demonstrated that PA levels
do increase for PARS participants in the long term, but the dropout rate can be
concerning. By using a mixed-methods approach, the lived experience of participants
enhances the understanding of reasons behind non-adherence. The comparative
study involving LGM and AOR samples showed that interventions with elements of
MI might be a better investment of commissioned resources.
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Acknowledgements
I wish to express my gratitude to everyone that has been part of this journey, with a
special mention to the study participants who generously gave their time and
experience. I am grateful to my team of supervisors: Professor Carol Phillips for
sharing her extensive knowledge of the PhD process, Doctor Natalie Walker for
guiding my behaviour change knowledge and use of SPSS and for her continued
support throughout the later stages, Doctor Mike Gillespie for continuing to support
my progress even with a move to USA, and Doctor Jeff Breckon for sharing his
understanding of MI.
I am also grateful to the Public Health Commissioners, Karen and Stephen, for
sharing the AOR protocol, Graham from the PCT who supported me immensely in my
work with the AOR database, Jackie Browne for giving me access to AOR meetings,
and Commissioner Michelle Aveyard for bringing the network together for the LGM
study. Thanks also to Paul Rice for answering my numerous questions about SPSS
and to Professor Campbell for helping me with the power calculation. I am grateful
to the staff at Leicester Terrace Health Centre in Northampton and Doctor David
Smart who gave me access to participants for the LGM study.
I am especially grateful to my family and friends who have continued to believe in
me. Vicky and Daniela for kindly proofreading the thesis, Tanya for listening to me
during those early morning runs, and Jayne for affirming I am enough.
Finally, I would like to thank everyone that I have had the privilege to teach physical
activity to, be it as part of a hard-core spinning class, an outdoor running session, or
recently, Yoga practice with all members of BALANCE KMC – you have all taught me
so much.
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Table of Contents

Abstract i
Acknowledgements iii
Table of Figures ix
List of Tables x
Glossary of Abbreviations xi
Chapter 1 Introduction 1
1.1 The Problem of Physical Inactivity 1
1.2 PA as a Solution 3
1.2.1 A brief overview of the physical benefits of PA. 4
1.2.2 Mental health benefits of PA. 4
1.3 Government PA Guidelines 6
1.4 Evolving NHS PA Policy 7
1.5 UK-based Legislative PA 8
1.6 Models of Behaviour Change 9
1.6.1 Transtheoretical model. 11
1.6.2 SDT. 16
1.6.3 SDT, TTM, and MI. 21
1.6.4 Summary. 21
1.6.5 Gaps in literature 23
1.7 Epistemological Approach 23
1.8 Thesis Outline and Research Contribution 25
1.9 NHS Ethics 27
Chapter 2 Northamptonshire Activity on Referral: October 2009 - September 2010
(Study 1) 28
2.1 PA interventions in UK Primary Care 28
2.2 Physical Activity Referral Schemes (PARS) 28
2.3 Effectiveness of PARS 31
2.3.1 Attendance and adherence. 32
2.3.2 PA behaviour change. 35
2.3.3 Social engagement during PARS. 36
2.3.4 Cost effectiveness. 37
2.3.5 Impact of the health professional on PARS effectiveness. 39
2.3.6 PARS research recommendations. 39
2.3.7 Gaps in knowledge in the literature on PARS. 41
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2.4 AOR Northamptonshire 42
2.4.1 AOR Northamptonshire protocol. 42
2.5 Aim and Objectives 44
2.5.1 Aim of the study. 44
2.5.2 Objectives. 44
2.5.3 Hypotheses. 44
2.6 Methods 45
2.6.1 Participants. 45
2.6.2 Data collection. 45
2.6.2.1 Induction and exit. 46
2.6.2.2 Six- and twelve-month follow-up. 47
2.6.3 Measuring PA. 47
2.6.4 Measuring knowledge, skills, and attitudes. 49
2.6.4.1 Knowledge. 49
2.6.4.2 Skills. 50
2.6.4.3 Attitudes. 51
2.6.4.4 Stage of change. 51
2.6.5 Data collation. 52
2.6.6 Statistical analysis. 53
2.7 Results 54
2.7.1 Number of referrals and attendance. 54
2.7.2 Sex and age. 55
2.7.3 Ethnicity. 55
2.7.4 Reason for referral. 56
2.7.5 Leisure provider. 57
2.7.6 Self-reported PA level. 57
2.7.7 Knowledge, skills, and attitudes. 59
2.7.7.1 Knowledge. 59
2.7.7.2 Attitudes and skills. 60
2.7.7.3 Stage of Change. 62
2.7.8 Inferential results. 62
2.7.8.1 Differences in independent variables over time. 64
2.8 Discussion 68
2.8.1 Application to theory. 75
2.8.2 Study limitations. 77
Chapter 3 Lived Experiences of Non-Adhering AOR Participants: An Interpretative
Phenomenological Analysis (Study 2). 78
3.1 Introduction 78
3.2 Qualitative Research 81
3.2.1 Interpretative Phemenological Analysis. 84
3.3 Aim 85
3.3.1 Research question. 86
3.4 Methods 86
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3.4.1 Participants. 86
3.4.2 IPA interview schedule. 88
3.4.3 Data analysis. 88
3.4.4 Trustworthiness. 90
3.5 Results 92
3.5.1 Researcher participant background notes. 92
3.5.3 Member check. 94
3.5.4 Themes. 94
3.5.5 Referral to AOR. 96
3.5.5.1 Medical referral. 96
3.5.5.2 Leisure centre. 100
3.5.5.3 Improvements. 105
3.5.5.4 Referral process summary. 111
3.5.6 PA. 111
3.5.6.1 Perception of PA. 111
3.5.6.2 Current PA. 117
3.5.6.3 Future PA intentions. 122
3.5.6.4 PA summary. 125
3.5.7 Self. 126
3.5.7.1 Physical. 126
3.5.7.2 Mental. 128
3.5.7.3 Social. 129
3.5.7.4 Quality of Life. 131
3.5.7.5 Self summary. 132
3.5.8 Relationships with others. 133
3.5.8.1 Health professionals. 133
3.5.8.2 Fitness professionals. 134
3.5.8.3 Family, friends, and others. 135
3.5.8.4 Relationships with others. 137
3.5.9 Behaviour change talk. 137
3.5.9.1 For. 138
3.5.9.2 Against. 139
3.5.9.3 Ambivalence. 140
3.5.9.4 Behaviour change talk. 141
3.5.10 Key messages of non-adhering AOR participants. 142
3.6 Discussion 143
3.6.1 Positioning themes in a theoretical context. 146
3.6.2 Reflections on the research process. 148
3.6.3 Research limitations. 149
Chapter 4 A Comparison of the International Physical Activity Questionnaire and the
General Practice Physical Activity Questionnaire (Study 3). 150
4.1 Measuring PA 150
4.1.1 Self-reporting questionnaires. 152
4.2 IPAQ 153
4.2.1 Validity and reliability of IPAQ. 154
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4.3 GPPAQ 155
4.3.1 Summary of IPAQ and GPPAQ. 156
4.4 Aim and Objectives 157
4.4.1 Aim. 157
4.4.2 Objectives. 157
4.4.3 Hypothesis. 157
4.5 Methods 157
4.5.1 Participants. 157
4.5.2 Data collection. 158
4.5.3 Data cleansing. 158
4.5.4 Data coding. 159
4.5.4.1 IPAQ coding. 159
4.5.4.2 GPPAQ coding. 160
4.5.5 Data analysis. 161
4.6 Results 161
4.6.1 IPAQ and GPPAQ data. 161
4.6.2 Frequency of IPAQ and GPPAQ PA levels. 161
4.6.3 Cross-tabulation of GPPAQ and IPAQ. 163
4.6.4 Chi-square (Х2) analysis. 164
4.7 Discussion 164
Chapter 5 Adherence and PA Behaviour Change during PARS with MI (Study 4). 167
5.1 Let‟s Get Moving 167
5.2 MI and Behaviour Change 171
5.3 Aim and Objectives 178
5.3.1 Aim. 178
5.3.2 Objectives. 178
5.3.3 Hypotheses and Research Questions. 179
5.4 Methodology 179
5.4.1 Participants. 179
5.4.2 Measures. 180
5.4.3 Data collection. 181
5.4.4 MI team. 181
5.4.4.1 Training. 181
5.4.4.2 MI sessions. 182
5.4.4.3 MI reliability. 183
5.4.5 Data analysis. 183
5.4.6 Comparison of AOR sample and LGM. 184
5.5 Results 185
5.5.1 Participants. 185
5.5.2 Adherence. 185
5.5.3 IPAQ level. 185
5.5.4 PHQ-9 score. 186
5.5.5 IPAQ MET values and PHQ-9 level correlation. 187
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5.5.6 MITI coding. 189
5.5.7 CARE measure. 190
5.5.8 AOR sample and LGM adherence comparison. 190
5.6 Discussion 190
5.6.1 PA behaviour change. 192
5.6.2 Depression levels. 192
5.6.3 AOR versus LGM adherence. 193
5.6.4 MI and behaviour change. 194
5.6.5 Reflection of theoretical context. 196
5.6.6 Research limitations and future research. 198
Chapter 6 – Conclusion 200
6.1 Current Knowledge 200
6.2 Summary of Main Findings 202
6.3 Contribution 205
6.3.1 Theoretical contributions. 205
6.3.2 Practical contributions. 208
6.3.3 Methodological contributions. 209
6.4 Research Limitations 211
6.5 Future Research 212
References 215
Appendices 236
Appendix A.1 - Research dissemination 237
Appendix B.1 - AOR Referral Process 240
Appendix B.2 - AOR 6 and 12-Month Follow-up Questionnaires 243
Appendix B.3 - AOR Study 6 Month 246
Appendix B.4 - IPAQ Self-Administered Short Form 248
Appendix C.1 - IPA Study Participant Invitation Letter and Semi-Structured
Questionnaire 251
Appendix C.2 – Dav‟s Transcript and Transcript Analysis 256
Appendix D.1 - GPPAQ 309
Appendix E.1 - LGM Study Questionnaire 310
Appendix E.2 - MITI Coding Template 320
Appendix F.1 – QMiP Journal Article 323