General practice referral of ‘at risk’ populations to community leisure services: applying the RE-AIM framework to evaluate the impact of a community-based physical activity programme for inactive adults with long-term conditions

A district council located in a rural part of South West England led the CLICK into Activity programme. It was funded by Sport England for 3 years from September 2015 with matched funding support from local partners. A project management team (including members of the district council, local partners and Sport England) developed the programme, including individual and organisational recruitment targets and programme content. The authors were not involved in the programme development phase; involvement was limited to evaluation of the programme.

Gatekeepers from nine GP surgeries agreed to participate in GP referral to community-based physical activity, and three trained exercise specialists experienced in working with inactive adults were recruited to deliver the physical activity sessions. At the time of programme delivery there was no local provision for GP referral that met the UK’s recommendations for promoting physical activity among those with long-term conditions [19].

Initially, patients diagnosed with type 2 diabetes, pre-diabetes and/or hypertension and registered at a participating GP surgery were referred to community-based physical activity through one of two channels: 1) Direct contact with a General Practitioner or health care professional during a routine appointment or, 2) GP surgery mail-out to potentially eligible patients based on medical records. Eligibility to participate in the programme was also determined by physical activity levels; only those classified as ‘inactive’ (individuals reporting total physical activity of 30 or fewer minutes per week) [20] were invited to attend. Early participant recruitment to the programme was low, and so the eligibility criteria were relaxed in December 2017 to include obese and overweight individuals (with a body mass index (BMI) > 25 kg/m²).

During an initial consultation with an exercise specialist, eligible participants had the opportunity to discuss suitable physical activity options and were encouraged to attend at least one physical activity session per week, but there was no minimum or maximum number of sessions that each participant could attend during their 12-week enrolment period. The physical activity sessions were delivered by exercise specialists, trained in motivational interviewing, in local leisure centres and other community venues, and offered a range of group-based activities (i.e. sessions attended by two or more individuals) in response to evidence supporting group-based physical activity promotion [11, 12]. Sessions were delivered at various times throughout the week, and included circuit training, walking groups, and adapted sports (e.g. seated volleyball). The project management group used local long-term conditions data held by participating surgeries to set a recruitment target for participants. The project aimed to support 1080 participants to attend and participate in at least one 30-min CLICK into Activity session during the 12-week enrolment period.

A logic model, presenting the programme delivery plan and hypothesised outcomes can be found in Additional file 1.

To generate evidence on each dimension of the RE-AIM framework a mixed methods approach was utilised. CLICK into Activity participants provided individual-level data, while organisational-level data were collected from members of the project steering group and the exercise specialists responsible for delivering the programme. Consistent with methods utilised in previous applications of the RE-AIM framework in the area of physical activity promotion, [21, 22] data were obtained from a range of sources: questionnaires, qualitative interviews, and programme-related documentation (Table 1). Evaluation data were collected between September 2015 and June 2018.

This study was granted ethical approval by the University of the West of England Ethics Committee. All participants were provided with information about the evaluation and gave written informed consent to participate.

Questionnaire data were entered into IBM SPSS Statistics (v.22.0). IPAQ questionnaire data were cleaned in line with IPAQ guidelines [28]. Descriptive statistics were generated for each outcome of interest at each time point. Linear mixed models for repeated measures over time were used to assess whether CLICK into Activity had an effect on participants’ physical activity, mental wellbeing and grip strength outcomes, with fixed effects of time and initial participation in at least one CLICK into Activity session. Models were adjusted for baseline socio-demographic characteristics (age, sex, BMI) and GP surgery. This approach was used to account for repeated measures over time and to prevent listwise deletion due to missing data [29]. Data were found not to be missing completely at random (Little’s MCAR test, p = 0.00) and subsequent missing value analysis indicated that data were missing at random. Bonferroni adjusted post hoc tests compared outcomes to each time point (baseline, 3-month follow-up, 6-month follow-up and 12-month follow-up) to estimate means and 95% confidence intervals (95% CI) for changes in outcomes.

Qualitative audio data were transcribed verbatim and analysed using NVivo 10 (QSR International). Data were explored using thematic analysis, [30] with the coding process based predominantly on mapping data against each of the RE-AIM dimensions in line with recently published guidance [31]. Analysis aimed to generate a balanced assessment of the programme and the factors that may have had an impact on the reach, effectiveness, adoption, implementation and potential sustainability of CLICK into Activity. Data saturation was reached when further coding was no longer feasible [32]. To confirm accuracy and interpretation of the data during the coding process and at theme development, findings were discussed and agreed between authors and reported in line with COREQ guidelines (see Additional file 3, [33]).

Programme cost data were categorised according to stage of programme delivery as follows: programme preparation cost estimate; programme delivery cost estimate; and, programme research and development cost estimate, to reflect the actual mainstream costs of the programme in a real-world delivery scenario.

Triangulation methods [34] were utilised to explore complementary and concurrently collected quantitative and qualitative data, considering evidence from different perspectives with the aim of developing a comprehensive understanding of the population impact of CLICK into Activity, from GP referral to CLICK into Activity session delivery. Consistent with previously utilised methods, [22] data from all sources were synthesised across each dimension of the RE-AIM framework. Programme reach, effectiveness and maintenance were assessed quantitatively using self-report and objectively measured data provided by CLICK into Activity participants. Evidence pertaining to effectiveness and maintenance domains is presented together in response to the quantitative analysis approach undertaken. Semi-structured interview data from a range of programme stakeholders were used to provide insight into factors influencing each dimension of the RE-AIM framework. Programme-related documentation, including attendance records and cost data, provided evidence for programme reach, adoption, and implementation.

Of those eligible to participate in CLICK into Activity (N = 602), the majority were referred to the programme due to diagnosis of pre-diabetes, type 2 diabetes or hypertension (N = 558, 92.6%). Following relaxation of the eligibility criteria in December 2017, 22 participants were referred due to being obese or overweight (3.7%), and 22 were referred for having a combination of long-term conditions (3.7%). Table 2 reveals that the majority of participants were female (N = 379, 63.0%) and just over half of participants were aged 70 or above (N = 309, 51.3%). Most participants identified as being of White ethnic origin (N = 580, 96.3%) and just over one fifth were qualified to degree level (or equivalent) (N = 128, 21.3%). Almost one third of participants reported an annual household income of between £10,000 and £20,000 (N = 177, 29.4%), and most participants described themselves as being in a relationship (N = 394, 65.5%). More than 80% of respondents had a baseline BMI within the overweight and obese categories (BMI ≥25 kg/m², N = 503, 83.6%).

A range of communication strategies were employed to reach the target audience, including newspaper advertising, display screens at participating GP surgeries, local community sites (online and print), and flyer distribution by exercise specialists in the local area, all advertising the programme. Despite utilising various communication channels, recruitment was low at the outset of the project. However, approximately 18 months into project delivery GP surgeries agreed to a mail-out to all patients diagnosed with at least one of the long-term conditions targeted by the programme. Recruitment figures were seen to increase following mail-outs, and qualitative interviews suggested that a wide ranging and long-term promotional strategy was essential.

I think continual promotion [is important] because there can be a lot of promotion at the beginning of the project, but then not so much as you get into the project. There hasn’t been continual promotion with the practice managers. You can’t just do [promotional activities] once and expect it to filter through to everybody. Exercise specialist 3

CLICK into Activity aimed to support 1080 individuals to attend and participate in at least one 30-min physical activity session during the 12-week programme. Of the 602 eligible individuals that provided baseline data individuals that provided baseline data, attendance records revealed that 326 participants attended at least one 30-min session (30.2% of 1080 target population). These participants attended nine sessions, on average, during the 12-week programme (M = 8.6, SD = 6.0). Just over one third of participants attended at least 12 sessions during the 12-week enrolment period (N = 104, 32%). These figures suggest that CLICK into Activity sessions were well-liked by participants in that once they had attended one session they often returned for more. As shown in Table 2 analysis identified no differences in sex, ethnicity, relationship status or baseline BMI between those that attended a CLICK into Activity session and those that did not (p > 0.05). There was a significantly higher proportion of those aged 70 or above attending a session compared with those that did not (55.2% vs 46.5%, respectively; p = 0.01).

Interviews with stakeholder groups identified a range of barriers and facilitators influencing initial participation in a physical activity session. For example, individual-level factors such as personal motivation to lose weight, concerns regarding potential for exacerbating existing health issues, and the fear of embarrassment, were noted. Wider social- and environmental-level factors, including activity scheduling and social support from family, friends and the community were also identified. Qualitative interviews also highlighted the importance of the physical environment, for example the influence of the rural setting on perceptions of neighbourhood safety and subsequent participation.

In rural Somerset the evening sessions were not successful, and that was down to the target population not feeling confident going out when it was dark. So, when the winter came, and the nights were drawing in people weren’t feeling comfortable leaving their house to go to an activity session. Exercise specialist 3

Table 3 presents descriptive statistics for CLICK into Activity outcomes for each data collection point. Linear mixed models analyses revealed time to be a significant predictor of vigorous physical activity, moderate physical activity, walking, sport, total physical activity, sitting time, mental wellbeing, and grip strength (p < 0.001). Time and initial participation interactions were not found to be statistically significant (p > 0.05).

As shown in Table 4, follow-up pairwise comparisons using Bonferroni adjustments revealed significant baseline to follow-up improvements in vigorous physical activity, moderate physical activity, walking, sport, total physical activity, sitting time, and mental wellbeing across each time point (p < 0.05). There was a significant improvement in grip strength from baseline to 3-month and baseline to 12-month follow-up (p < 0.05), but this change was not evident at 6-month follow-up (p = 0.15). Although measures were taken to reduce the effects of missing follow-up data in our analysis, [29] 6- and 12-month follow-up response rates were low and as such, these findings should be treated with caution.

Qualitative interviews with CLICK into Activity participants were consistent with quantitative findings, in that numerous positive changes were identified in participants' outlook and perceptions of their health and wellbeing as a result of being referred to the programme. These included increased mobility, weight loss, reduced symptoms from long-term conditions, increased core strength, and increased purpose and feelings of happiness.

To sum it up in a sentence, it’s brought me back to life. It’s as if I have been in hibernation. I’m a lot happier, fitter, and I can do that little bit more...I’ve lost quite a lot of weight, and I am a happier, happier person since. It’s given me more hope and a more positive attitude. It just does me so much good. I even bought a t-shirt, believe it or not. It says, ‘I got CLICKed into Life’. Participant 3

At the end of the 12-week enrolment period, CLICK into Activity participants were signposted to a range of alternative local physical activity classes. Feedback from qualitative interviews indicated that these were best received when personally recommended by an exercise specialist, as they were seen to provide trusted advice. Data also suggested that participants held positive intentions to continue to participate in physical activity after completing the programme. Participants were asked to discuss their views on paying for a service such as CLICK into Activity in the future. Most participants accepted that for such a programme to be sustained a personal contribution towards running costs was to be expected. However, it was also acknowledged that most attendees were of pensionable age with limited disposable income, so subsidised rates would be welcomed.

At an organisational level, steering group members reflected upon the potential sustainability of the programme, and highlighted concerns about engagement from GP surgeries beyond project funding.

Everyone was very enthusiastic [about the GP referral process] at the beginning [of the project] but it’s tailed off and I think this is because of the pressures that the [GP] surgeries are under. People have stopped thinking about good ideas and prevention but just gone to fire-fighting mode. General Practitioner

Referral to physical activity sessions continued at seven of nine surgeries until the end of project funding, but maintenance of the programme from referral through to activity session delivery beyond this time was uncertain due to the challenging economic climate.

A total of nine GP surgeries adopted CLICK into Activity for at least some of the programme delivery period. Eight surgeries were originally invited to participate in the programme at the outset, but two were withdrawn due to low recruitment rates and low project buy-in; one 2-years into project delivery (November 2017) and the other in June 2018. In June 2017 a ninth GP surgery was invited to participate.

Interviews with members of the project steering group revealed that a surgery’s decision to adopt the CLICK into Activity programme was associated with a range of engagement activities with practice staff arranged in advance of programme sign-up and delivery. One example included a talk from an external General Practitioner with a specialism in physical activity; this was thought to highlight the importance of physical activity promotion, and thus increase buy-in at staff and setting levels. Qualitative interviews also identified the importance of the presence of a GP staff member visibly recommending and championing the programme in advance of programme adoption. For example, an interview with the CLICK into Activity project manager revealed that the practice manager of one GP surgery - the surgery that was invited to adopt the project following the withdrawal of two originally recruited surgeries - had lobbied for involvement with the project from its initiation and was highly enthusiastic about physical activity promotion. The CLICK into Activity project manager felt that without this enthusiasm from one member of the team, the surgery and its staff would not have agreed to adopt the programme.

Exercise specialists reported that a key influence on effective GP referral implementation was the presence of a practice manager or staff member who had an appreciation for the value of physical activity for patients with, or at-risk of a long-term condition. Notably, an assessment of programme documentation found that the late joining surgery referred 66 participants in 12 months (11.0% of total sample), while the two surgeries withdrawn from the project referred only 49 participants between them (8.1% of total sample). One of the exercise specialists expressed surprise at the attitudes of some health professionals at participating surgeries. It was noted that physical activity was not always seen as a priority prevention strategy, and that this had a negative impact on successful implementation.

I thought ‘Great I’m going to be a team with the doctors, we are going to really work together’. I thought doctors would know the benefits of exercise, but I was shocked to see that some of them needed educating. They didn’t believe in exercise. Exercise specialist 1

Reflections on physical activity session implementation revealed that exercise specialist characteristics were integral to success. Participants reported that exercise specialists created a safe and supportive environment, instilling confidence in them from initial consultation to the end of the programme. Support and guidance from exercise specialists to participate in appropriate tailored physical activity was perceived to promote increased feelings of control over participants’ health and wellbeing. Participants also reported feelings of increased self-worth and happiness because of their engagement with exercise specialists.

The only words to describe [the exercise specialist] are ‘excellent’ and ‘awesome’. She is very, very dedicated. She deserves a medal, literally. She is very, very good; she knows what she’s doing. Participant 2

Another important feature of programme implementation success was the group delivery of CLICK into Activity sessions. Programme sessions created an opportunity for social engagement with members of the local community with similar health profiles. Many participants reported feelings of social isolation prior to CLICK into Activity, which improved through meeting new people and building social support through the programme.

I think everybody was a bit nervous to start, and then as you got to know people and more and more people joined, the old [participants] were, like, helping the new [participants]. It was just amazing because everybody said they were so nervous, and the older [participants] made the new [participants] feel so welcome. Participant 3

Qualitative interviews with CLICK into Activity participants also revealed that the content of the physical activity sessions was important, with praise for circuit training activities tailored to individuals’ needs and abilities. In response to the popularity of circuit training sessions observed through attendance figures and anecdotal feedback provided to exercise specialists, the CLICK into Activity schedule was adjusted over time, with the provision of adapted sports sessions reduced in the final year of project delivery to allow additional capacity for circuit training.

The type of class was important. We did have adapted sports, like table tennis and then Boccia and ‘new age’ curling. Some of these are really good fun to attend but I think for this type of project [with inactive adults], the circuit style delivery is better and [it] was much more popular. I think this was because people felt they were getting more for their time. The numbers are picking up where adapted sports has been swapped for circuits. Project manager

[The exercise specialist] knows how to sort of treat us ‘older people’, in the fact that caution has to be adhered to. You know, you don’t want to push people too hard. Participant 10

Interviews revealed that successful implementation of the programme was reliant on good communication across all levels of programme delivery. It was reported that quarterly steering group meetings were not always well attended due to competing pressures on project partners’ time, but they were perceived to provide an opportunity to share good practice and draw upon expertise from those working in a different field but working toward the same objective.

As shown in Table 5, the total cost of CLICK into Activity implementation over 3 years was £174,396 (2017–18 prices), based on total annual delivery and preparation costs. The average cost per person attending at least one CLICK into Activity session was £535. Annual preparation cost estimates, including training expenses, were relatively consistent (~£3000–£4000 each year), while delivery costs were seen to reduce over time as the programme became more established. Research and infrastructure development costs, including IT infrastructure, and evaluation and research expenses totalled £67,500 over 3 years. These costs were excluded from the total cost of implementation, as they would not apply to mainstream implementation.

Strengths of the study include application of the RE-AIM framework, including collation and triangulation of qualitative and quantitative data from a variety of sources; overcoming challenges in the evaluation of physical activity programmes [22, 39, 49] and social prescribing schemes [41‐43] that have been reported previously. Limitations of the study include a lack of control or comparison group. Secondly, we were unable to recruit individuals that never participated in a CLICK into Activity session to participate in a qualitative interview; this limits our understanding of the barriers influencing initial engagement and participation. Thirdly, while our statistical approach was chosen precisely to mitigate the effects of missing data [29], 6- and 12-month follow-up response rates were low, which limits understanding of longer term programme effects. Fourthly, physical activity outcomes were based on self-report data collected by trained exercise specialists. Given reports of positive rapport developed between participants and exercise specialists, it is possible that participants over-reported activity levels for social approval, as observed in previous studies [50, 51]. The collection of physiological data relating to participants’ long-term conditions (for example, HbA1c levels among those participants with type 2 diabetes) was beyond the remit of this evaluation. In the case of type 2 diabetes, studies have shown that physical activity can improve glycaemic control among diabetic populations [52] and it could reduce type 2 diabetes incidence [53]. Future studies examining physiological as well as physical and mental health outcomes would be beneficial.