The impact of physical activity promotion by health professionals on physical activity levels of adults & young people receiving outpatient care (PROMOTE-PA study)

This is a hybrid type I implementation effectiveness trial involves: a) Implementation strategies delivered by the research team to health professionals to support them to incorporate physical activity (PA) promotion into their routine care; and b) Evidence-based intervention (PA promotion) delivered by health professionals to their patients within their routine care. IMPLEMENTATION STRATEGIES The research team will work with all sites during a “Service Mapping” phase prior to site randomisation. All sites will take part in this Service Mapping process which will occur 4 weeks prior to the Implementation Period (intervention group) or 4 weeks prior to baseline (delayed support group). In this Service Mapping phase the research team will work with clinical team leaders at each site to identify factors relevant to the implementation process, including team members, clinical processes, patient journey, readiness for implementation, current PA promotion practices, and barriers and facilitators to PA promotion for health professionals and for patients. Clinicians in sites randomised to the intervention group (early implementation support) will be offered implementation strategies to support and train them to incorporate PA counselling into their routine practice. Implementation strategies will be tailored to each site based on pre-implementation work conducted in PROMOTE-PA part 1 and the service mapping process. All sites in the intervention group will receive access to the educational online resource hub, and then sites will be offered additional implementation strategies (see additional options below). Those in the control group (delayed implementation support) will be offered the same strategies after completion of the control period. The implementation strategies are based on literature describing barriers reported by health professionals that stop them from incorporating PA counselling into routine practice, as well as literature on existing programs and resources promoting PA in similar populations. The multi-faceted implementation strategies have also been informed by findings from pre-implementation work (PROMOTE-PA part 1 qualitative study conducted in 2022-23) which included consultation with local clinicians, community providers and patients to ensure the correct local influences are addressed. All teams in the intervention phase will be given access to the online education & training resource hub (Implementation strategy 1). Implementation strategies 2-4 will be offered to all sites and tailored to the needs of each site. Implementation strategy 1: Education and training – all teams Mode of delivery/ where/ length: Online resource hub accessible through website. Maximum duration needed to review all content = 3 hours. Time- frame: From the start of the implementation period onwards. Intervention content: The online resources contain information, case studies and training videos supporting PA promotion as per the 5A’s approach outlined below, and implemented across diverse clinical areas relevant to the study sites (e.g. older adults, paediatrics, rheumatology, physiotherapy, etc). The training videos have been developed specifically for this study. Additional resources include: a comprehensive geographical map and list of community physical activity opportunities; Short educational videos presenting simulated clinical scenarios of health professionals delivering PA promotion targeting knowledge gaps identified in PROMOTE-PA part 1 pre-implementation study; Links to health professional and patient-facing resources on PA benefits, disease-specific considerations, examples of different physical activity options. Resources will include links to available resources e.g. Moving Medicine https://movingmedicine.ac.uk/; WHO: https://www.who.int/health-topics/physical-activity; and copies of study developed resources. Web portal analytics will be used to track usage of the different components of the online resource hub as a measure of adherence. Implementation strategy 2: Tailored strategies to address community referral barriers Mode of delivery/ where/ length: This will be tailored and determined with each team to address their specific context and the barriers they have with community referrals for their patients. Time- frame: Start of implementation period Intervention content: Research staff working with the PROMOTE-PA team will work with individual sites to provide training in finding PA opportunities, help to develop links with PA providers and/or develop referral resources. New models of service delivery will also be developed where indicated to support patients transitioning from hospital-based to community-based physical activity opportunities. Ongoing contact will be maintained with individual sites via weekly face-to-face visits during the implementation period, and via weekly phonecalls/emails during the remainder of the study period. A study audit of contact logs will be conducted to monitor adherence to the intervention. Implementation strategy 3: Experts and clinical mentors Mode of delivery/ where/ length: Mixed, online and in-person. Time- frame: Start of implementation period Intervention content: Could include presentations (e.g. how to do PA counselling) and Q&A sessions/discussions on incorporating PA promotion into clinical practice. These experts & clinical mentors have extensive experience in implementing PA promotion strategies in various clinical areas relevant to the study population (e.g. frail older adults, paediatrics, physiotherapy). These sessions will last approximately 60 minutes and take place once per fortnight during the study period. An audit of session attendance records will be conducted to monitor adherence. Implementation strategy 4: Clinical champions Mode of delivery/ where/ length: Mix of face-to-face & online delivery to clinical champion identified at each site Time- frame: Start of implementation period Intervention content: Identifying and supporting clinical champion at each site to drive implementation of PA promotion into routine practice. Support offered could include to identify/ modify/ develop resources for their team (including local Activity Directory or similar resource), identify & connect with appropriate PA opportunities, modify clinical assessment forms to include PA information to collect, audit and feedback with colleague between workshops. An audit of clinical champion correspondence & workshops will be conducted to monitor resources provided. EVIDENCE-BASED INTERVENTION The model for PA promotion within routine care in this trial is informed by the ‘5As’ promotion model: 1) Assess - All health professionals will be encouraged to assess their patients’ PA levels, provide brief advice about PA and implement one or more of the PA approaches as per the agreed implementation plan for that clinical team. Follow up actions may include any or all of the following approaches (depending on each team’s client groups, clinical setting, and capacity): 2) Advise - make specific recommendations and advice on suitable PA options 3) Agree - collaboratively set goals and develop a PA action plan 4) Assist - collaboratively identify barriers and potential solutions 5) Arrange - arrange referral to a PA program with follow-up Clinicians in the early implementation support group can also refer their patients who are interested, to the Physical Activity Linkage Program. Patients who participate in the Physical Activity Linkage Program will receive: I. Assessment - An initial session of up to 1 hour from an experienced physiotherapist or exercise physiologist to identify what support they may need/want to be more active. This session may be provided face to face, on the phone or online. II. Tailored advice about suitable PA opportunities in the community. III. Development of an individualised plan to help the patient increase their PA that includes referral to suitable PA opportunities/services. IV. An optional second session with an experienced physiotherapist or exercise physiologist to discuss the plan and provide additional support to help the patient get started and keep on being active. An audit of session attendance checklists will be conducted to monitor adherence to the intervention. PA promotion seeks to change health behaviour as a means of primary or secondary prevention of life-style related chronic health conditions. This may include physical activity counselling intervention which is underpinned by theoretical models of behaviour change (COM-B, Self Determination Theory, Social Cognitive Theory), Motivational Interviewing and incorporates behaviour change techniques shown to increase PA in the general population as well as people with physical disabilities.