Implementation and referral of the ecofit physical activity intervention within Diabetes Alliance Program Plus among regional and remote type 2 diabetes patients in a primary care setting.

This study is a component of Diabetes Alliance Program Plus (DAP+)As part of DAP+, which has been registered with ANZCTR (ACTRN12622001438741). ecofit is a community-based multi-component resistance and aerobic-based physical activity intervention with established efficacy in adults at risk of/diagnosed with Type 2 diabetes, and effectiveness in community-dwelling adults failing to satisfy physical activity recommendations. A scaled up community-based hybrid type III implementation study is currently being undertaken in Newcastle/Lake Macqurie, NSW, Australia (ACTRN12624000261516). This current study will outline the steps in implementing ecofit in a primary care setting in regional and rural Australia, within the larger DAP+ study. As part of DAP+, consenting patients will attend two 40-minute case conferences at baseline and 6-month follow-up. The case conferences take place at the patient’s general practice/AMS and are attended by a visiting tertiary specialist team, a GP and practice nurse or Aboriginal health practitioner. Several clinical outcomes will be measured during these appointments. During case conferences, patients can be referred to one of the three lifestyle modules (physical activity, nutrition and mental health). ecofit is the physical activity module in the DAP+ study. Patients will also complete a nutrition and physical activity diary at each timepoint. This study will not report on the nutrition and mental health modules. In mid-late 2024 general practices involved in DAP+ will start to be provided with resources to promote ecofit. A record of general practices provided with resources will be kept. The resources include a trifold brochure with information for each DAP+ lifestyle module (includes QR codes that redirect people to the ecofit website), an ecofit information sheet for health professionals, talking points for encouraging patients to use ecofit and a short introductory video about ecofit. Individual general practices and diabetes educators will decide if they promote ecofit and how they do it. If a patient chooses to participate in ecofit, they will download the ecofit mobile application (app) from Google Play or the Apple App Store, or download PDF resources (same content as mobile app) from the DAP+ website (https://www.dapplus.org.au/). App users will be able to complete ecofit workouts using pre-generated workouts based on their skill and experience level, or they can create their own workouts. The app will also contain resources designed for encouragement and motivation based on behavior change theory, which has been assessed by a relevant consumer group. App usage will be at the users discretion. They can allow the app to send them reminders to complete workouts. Users will use the app for as long as they choose, there is no minimum or maximum time of app engagement. The app will prescribe predominantly muscle strengthening exercises with some aerobic exercises. Muscle strength exercises include bodyweight exercises, the use of household items (cans of food, plastic water bottles) as weights, and the use of outdoor gym equipment. Muscle strength exercises are placed into 4 levels, ranging from very simple (i.e. sit to stand, arm circles), to difficult (i.e. pull up, squats). Aerobic exercises include walking, running and the use of stationary exercises bikes and ellipticals found in outdoor gyms. App metrics will be used to measure app usage for participants 3-months after a patient registers an account with the app. All data will be de-identified. Primary care professionals will be provided with brief 20 minute training to promote ecofit to their patients in different settings. During case-conferences visits, staff of general practices will be provided with training to promote ecofit to the patients in the DAP+ study. Primary care workers attending larger DAP+ multidisciplinary conferences will also receive training to promote ecofit to patients. Conference presentations will range from 15 minutes to 30 minutes. The research team will provide training to the diabetes educators (DE) who attend each DAP+ case-conferencing session, prior to the first DAP+ case-conference visit that involved ecofit resources. A record of DEs who complete the training will be kept, When DEs train primary care staff in general practices, the research team will be informed of how many staff were trained. General practice staff will also complete a short survey that will indicate to the research team who has been trained to promote ecofit.