The development of an intervention to promote walking in primary care

Obesity has more than doubled in the UK over the past decade, largely because people are less active in their daily lives, e.g. by driving more and watching more television. Current government recommendations are that people should engage in at least 30 minutes of ?moderate or vigorous? exercise, for at least five days each week, to gain health protective benefits. However, over 60% of men and 70% of women in England and Wales do not meet these requirements, with activity decreasing with age. Health problems due to physical inactivity, such as diabetes, are expected to increase dramatically in the future as a consequence, and may soon overtake smoking as the behaviour which causes most ill-health and premature death.

This research aims to promote ?brisk? walking, i.e. walking that results in being slightly out of breath. Walking can be done by most people without any special equipment, at times that suit them. We have developed an intervention that can be delivered in about 10-15 minutes. It asks participants to set realistic goals for increasing their walking, boosts confidence by asking participants to recall instances when they have achieved these goals, and helps people put their good intentions into action, by making concrete plans. It helped 130 volunteers increase their walking, as measured by pedometers, from an average of 20 mins/day to 32 mins/day. These increases were maintained for at least six weeks.

This proposal aims to adapt this intervention so that it can be delivered in primary care by practice nurses and health trainers, targeted at patients for whom increasing physical activity is a health priority. It will be developed to be acceptable to those delivering it, easy to deliver as intended and acceptable to patients attending primary care. There is a need to develop a study of how much this intervention would affect walking if it were adopted more widely, and for how long increases would last. The intervention, including materials and training, will be developed and refined to maximise the acceptability of the intervention. Methods of evaluating the efficacy of this intervention will be developed, to recruit and retain people into the study, with acceptable measures of beliefs about walking, actual walking, and healthcare costs. It will also investigate the reasons why some people increase their walking and some do not. This will lay the basis for a more definitive study of the effectiveness of the intervention.

Walking is especially promising as a focus of public health interventions because it is acceptable among people who are least physically active, and also provides considerable health benefits. A recent systematic review showed that walking interventions can increase walking. However, the review included a mix of different types of interventions targeted at different populations, utilising different modes of delivery and different ways of measuring walking. This makes it difficult to identify the most effective types of interventions and the extent to which these interventions are sustainable, generalisable, and cost-effective, making interpretation to inform policy difficult.

The proposed research builds on research we have already conducted. Following extensive developmental work, a 10-15 minute intervention consisting of strategies to increase self-efficacy beliefs, and volitional strategies to help people translate their ?good intentions? into behaviour change was developed. This intervention yielded large effects on walking behaviour (as assessed by pedometers) in a sample of 130 ?well? volunteers: a mean increase from 19.8 minutes to 32.2 minutes per day (Cohen?s d = 0.82). These increases were mediated by changes in people?s confidence in their ability to achieve their walking goals, and were maintained for at least six weeks post-intervention.

The objective of this research is to develop the intervention and its evaluation so that it can be routinely delivered in primary care by practice nurses (PNs) and health trainers (HTs), targeted at patients for whom increasing physical activity is a particular health priority. This work on implementation will be necessary to ensure that the intervention is acceptable to a range of people delivering and receiving it, and maintains change over the longer time period necessary to translate behaviour change into a public health benefit. We propose three phases of research: (1) an initial iterative phase of piloting and refining the intervention, with feedback from those delivering the intervention and those receiving it, to maximise acceptability; (2) a piloted explanatory trial; (3) a full explanatory trial, to inform the design and conduct of a definitive pragmatic trial, including mediation analyses to assess how the intervention works, and preliminary economic evaluation of how much it costs, in addition to whether it works. The explanatory trial will be a cluster randomised trial, with 15 PNs/HTs and 210 patients in each arm, giving 85% power to detect a 5 min/ day increase in walking, as assessed by pedometers. Participants will be followed up for six months.