An education programme influencing health professionals to recommend exercise to their type 2 diabetes patients – understanding the processes: a case study from Oxfordshire, UK

Physical inactivity worldwide is responsible for 6% of the incidence of coronary heart disease, 7% of type 2 diabetes, 10% of breast cancer, and 10% of colon cancer [1]. In England (2011), only 13% of men and 7% of women aged 65+ achieved the recommended level of physical activity (150 min of moderate activity per week and muscle-strengthening activities on at least 2 days per week) [2]. As physical activity levels decline with age, the risk of ill-health, decreased physical functioning, and greater number of falls increases. Four million hospital day beds in England each year are accounted for by falls and fractures in those aged 65+ [3]. Whilst the physical activity guidance for older adults is clear, the challenge remains to increase uptake of physical activity within this group.

Inactivity has a greater impact on adults who have conditions such as type 2 diabetes. Of all the risk factors for type 2 diabetes – age, genetics, weight and ethnicity – weight (being overweight or obese) is the most important, since obesity accounts for 80-85% of the risk of developing the condition [4]. The rise in the prevalence of type 2 diabetes has led campaigners to advocate that the principal combating strategy should be to tackle the rise in obesity, through healthy lifestyle advocacy including ‘promotion of physical activity’ [5]. Increased physical activity, independent of weight loss, reduces the incidence of Type 2 diabetes [6].

Guidance from the National Institute for Health and Clinical Excellence (NICE) indicates that ‘brief advice’ from health professionals ‘has a modest, but consistent, positive effect on physical activity levels’[7], a strategy receiving government backing in the light of rising National Health Service (NHS) healthcare costs [8]. However, the practice of offering physical activity advice is currently not part of normal primary healthcare routines [9]. Recent evidence cites a number of barriers to health professionals offering ‘brief advice’. Primarily these include a lack of time, poor knowledge and training in exercise medicine education and behaviour change techniques, previous lack of success with changing patient behaviour, and lack of incentives to promote physical activity; if health practitioners were active themselves, this was an ‘enabler’ to the offering of ‘brief advice’ [10]. In England, exercise medicine education is not routinely part of medical training, nor is there a comprehensive professional development programme in place to provide healthcare professionals with risk reduction knowledge or behaviour change training [11].

Further, NICE advises that Care Pathway structures e.g., cardio-vascular disease, type 2 diabetes and stroke, should integrate exercise provision [12]. Currently, pathway provision structures do not support patients’ physical activity – rehabilitation schemes are fragmented and incomplete, lacking the resources to address exercise barriers. Provision beyond rehabilitation shows pathways as ‘often suboptimal leading to poor long-term adherence’ [13].

The Generation Games (GG) intervention aims to offer such integration by delivering exercise medicine education to health professionals through the Health Professional Education Programme (HPEP), encouraging them to offer exercise advice to their patients and providing a mechanism of provision of exercise to which they can refer. Following recommendation of GG to patients, and then contact being made by the patient, signposting from GG to appropriate exercise opportunities occurs by phone or letter. Secondary care pathway providers, having engaged with the GG offer (perhaps through attending an HPEP session), also signpost their patients – often in one-to-one settings – to pathway-specific exercise provision promoted by GG. The evidence base about the processes involved in such interventions is sparse, particularly in respect of the physical activity behaviour change in older populations. Other complex interventions have highlighted that changes in behaviour must incorporate both knowledge and motivation to change [14]. It is also unclear which educational delivery mode factors facilitates the greatest positive changes in professional practice [15, 16], given that health professionals may operate within unsupportive healthcare systems and cultures.