Promoting physical activity of working aged adults with selected personal approaches in primary health care : feasibility, effectiveness and an example of nationwide dissemination

Abstract

The primary aim of this study was to evaluate the feasibility and effectiveness of selected personal approaches to promote leisure time physical activity (LTPA) of working aged adults in primary health care. Three interventions were conducted in Southern Finland involving 35 health care units, 99 health care practitioners and 644 eligibility screened participants aged 18 to 65 years with no specific medical indication to increase LTPA.Intervention 1 was conducted in occupational health care (OHC) and the employees (N=155) from nine companies were randomly assigned to two experimental (EXP) and control groups (CON). In the first EXP group individual face-to-face counseling alone was implemented by occupational nurses. In the second EXP group face-to-face counseling was supported by fitness testing conducted by a physiotherapist. In CON only data collection was carried out. Four counseling sessions were implemented during the 12-month intervention.Intervention 2 took place in 24 health center and OHC units, where the physicians (N=67) were allocated randomly to EXP or CON. The group of each patient (N=265) was, therefore, physician-dependent. The approaches compared with usual care (CON) were Physical Activity Prescription by physicians during one routine appointment and self-monitoring of LTPA with a pedometer and LTPA log followed by mailed personalized feedback.In intervention 3, which was implemented in municipal maternity and child health care, the clinics (N=6) signed up for EXP or CON. Thus, the group of the pregnant (N=132) and postpartum women (N=92) was determined by the clinic. In EXP individual face-to-face counseling supported by an option for supervised group exercise once a week was provided by the public health nurses. The number of counseling sessions was five for eight to 37 weeks’ gestation in pregnant participants and for two to ten months after delivery in postpartum participants. In CON usual care was delivered.The components of the feasibility evaluation were integrity, participant responsiveness, applicability to routine health care practices and safety. The evaluation was based on questionnaires and /or interviews for practitioners and participants and on documents used in the interventions. In the effectiveness evaluation, short (2 months), mid (6 months) or long-term (> 6 months) differences in LTPA between EXP and CON were examined with questionnaires, pedometers or 7-day logs depending on the intervention.According to the feasibility results integrity and participant responsiveness were high and the approaches proved safe and applicable to routine health care appointments. As to the effectiveness results, Physical Activity Prescription byphysicians showed both short- and mid-term benefits in health centers and OHCcompared with usual care. The findings regarding self-monitoring were also encouraging, but only in the short-term. In maternity care, individual face-to-face counseling supported by optional group exercise proved effective in long-term while in child health care no changes in LTPA were observed. Individual face-to-face counseling with or without fitness testing were not beneficial in OHC compared to data collection only.The secondary aim of the study was to evaluate the nationwide dissemination of one of the approaches, Physical Activity Prescription. Dissemination was carried out with a multiorganisational program, the Physical Activity Prescription Program (PAPP). Evaluation was based on the RE-AIM framework (www.reaim.org) with five dimensions: Reach, Effectiveness, Adoption, Implementation and Maintenance.Reach was assessed by the number of prescriptions requested. The indicator of effectiveness was the change in physicians’ practices from 2002 to 2004 in asking patients’ physical activity habits and the indicator for adoption the change in the frequency of using prescription or other written material in physical activity counseling. The questions related to these indicators were added to the annual surveys of the Finnish Medical Association to all its member physicians in 2002 (N=16692) and in 2004 (N=17170). Maintenance was described by the number of local prescription projects and visibility in national health promotion documents. Process evaluation was used to assess implementation. According to the results, PAPP succeeded in all dimensions but effectiveness and adoption.In summary, the personal approaches examined were feasible in their original settings and target groups. The findings on effectiveness were less consistent. In light of this study and the literature on comparable studies in other countries, the strongest support is for the short-term effects of Physical Activity Prescription by physicians and for self-monitoring with a pedometer and a LTPA log followed by mailed feedback. Very little or inconsistent literature is available to support the other approaches. Thus, the results are limited to this study until determined by further research.Dissemination of Physical Activity Prescription by physicians at national level did not succeed in all dimensions. Extending the duration and putting more emphasis on local efforts might have improved both effectiveness and adoption. This study was among the first in Finland on the feasibility, effectiveness and dissemination of personal approaches to promote physical activity in primary health care. More research is therefore needed to determine the generalizability of the findings and also to specify whether some of the approaches are more feasible or effective than others.

Minna Aittasalo tutki väitöskirjassaan työikäisten liikunnan edistämistä avoterveydenhuollossa.- Aihe on tärkeä, koska arviolta 35-40 prosenttia suomalaisista aikuisista liikkuu terveytensä kannalta liian vähän ja terveydenhuollon ammattilaisilla on mahdollisuus tavoittaa suuri osa näistä ihmisistä, Aittasalo painottaa.Aittasalo totesi, että liikkumisreseptillä, askelmittarilla ja liikuntapäiväkirjalla saavutetaan hyviä tuloksia. Niiden käyttö terveyskeskuksissa ja työterveyshuollossa on perusteltua.- Uuden työtavan käyttöönotto vaatii kuitenkin aikaa ja paikallista yhteistyötä, Aittasalo huomauttaa.- Lääkärin laatima liikkumisresepti lisäsi terveyskeskusten ja työterveyshuollon asiakkaiden liikuntaa, Aittasalo havaitsi.Aittasalo selvitti samalla askelmittarin käyttöä ja liikuntapäiväkirjan pitämistä sekä niistä fysioterapeutilta saatua postipalautetta. - Nämäkin lisäsivät terveyskeskusten ja työterveyshuollon asiakkaiden liikuntaa, tosin vain lyhytaikaisesti.- Tehostettu liikuntaneuvonta äitiysneuvolassa auttoi naisia pitämään yllä reipastehoista liikuntaa raskauden loppuun saakka. Lastenneuvolassa sama neuvonta ei tuottanut tulosta, Aittasalo huomasi.Henkilökohtainen liikuntaneuvonta työterveyshuollossa ilman kuntotestausta tai kuntotestauksen kanssa ei lisännyt työntekijöiden liikunta-aktiivisuutta. Vertailukohtana olivat työntekijät, jotka eivät osallistuneet neuvontaan, mutta käyttivät askelmittaria ja liikuntapäiväkirjaa liikuntatietojen keruuseen.Aittasalo selvitti myös valtakunnallisen Liikkumisresepti-hankkeen (2001-2004) tuloksia. Hankkeen tavoitteena oli lisätä avoterveydenhuollon lääkärien antamaa liikuntaneuvontaa liikkumisreseptin ja tukimateriaalin avulla. Liikkumisresepti-hanke ei lisännyt liikkumisreseptin käyttöä eikä liikuntaneuvontaa lääkärien keskuudessa.Liikkumisreseptin käyttöönottoa koskevat tulokset ovat sopusoinnussa ulkomaisten tutkimusten kanssa: valtakunnalliset toimenpiteet tavoittavat kyllä kohderyhmän, mutta uuden menettelytavan käyttöönotto tapahtuu hitaasti ja asteittain ja sitä voidaan parhaiten edistää paikallisella tasolla.Aittasalo tutki erilaisten liikunnan edistämistapojen toteuttamiskelpoisuutta ja vaikuttavuutta avoterveydenhuollon aidoissa asiakaskontakteissa. Kolmeen osatutkimukseen osallistui yhteensä 35 terveydenhuollon yksikköä, 99 terveydenhuollon ammattilaista ja 644 asiakasta. Toteuttamiskelpoisuutta arvioitiin sillä, miten hyvin ne toteutuivat suunnitellulla tavalla, sekä asiakkaiden ja ammattilaisten näkemyksillä ja edistämistapojen turvallisuudella. Vaikuttavuutta arvioitiin asiakkaiden liikunta-aktiivisuudella. Liikunta-aktiivisuustiedot kerättiin kyselylomakkeilla, askelmittareilla tai liikuntapäiväkirjoilla. Vertailukohteena olivat asiakkaat, joiden kohdalla kyseisiä liikunnan edistämistapoja ei toteutettu.