Service provision
The AL service currently offers a maximum of 6 consultations per patient, which are generally held at monthly intervals. Very few of the participants had seen the AL advisor more than 4 times, with many having seen her only 2 or 3 times and then feeling confident of continuing on their own. When asked their views on consultations being held monthly, the majority of participants felt that this was about right – that meeting any sooner would not allow enough time to make sufficient changes, and that a longer interval would mean that they would lose motivation:
"Yes I liked it monthly because I felt as though you wasn't being watched and that you got chance to do everything you wanted. It wasn't a rushed thing thinking right I've got to get it done because I've got to see her next week, but I felt as though you saw more improvement to report to her."
(Female, 24 years)
This concurs with the findings of Hillsdon and Thorogood [
17] that regular follow-up increases the likelihood of sustained behaviour change.
One interesting finding from the discussion was that many of the participants felt that the service should be ongoing, and not limited to a certain number of consultations or a specific time period. While very few had needed six consultations, they were not in favour of the service being limited and being unable to see the AL advisor for 'check-ups':
"But after the sessions I wouldn't like to think that it is finished full stop, and that you're in the filing cabinet. I would like to think that you could go at least twice a year ... as you would to a doctor for a check-up. To go back to 'Sarah' just to see whether you had lapsed in anything, if you have forgotten anything, or if there is anything new on the market so to speak."
(Male, 67 years)
Between appointments the AL advisor offered telephone support as a way of helping participants stay motivated. Feedback during discussions suggested that while most participants found telephone support a very helpful and motivating aspect of the service, others did not and would not have been happy having someone "ringing me up and saying are you doing this? Are you doing that? " It appears that optional telephone support is appropriate and should remain as it is.
While not all participants were asked about this issue, as it only arose during one discussion group, those who were asked felt very strongly that the service and support should be ongoing. This issue should be explored and the implications of offering the service on a continuing basis should be identified. While on the one hand the participants clearly felt that this was important, and that without it they might fall back into old habits, there is also a need to encourage people to take responsibility for themselves and their health, and not become too dependent on health staff or services. This issue has been previously raised by Hunt and Hillsdon [
18]. Furthermore, if participants were able to continue seeing the AL advisor it would increase demand and time pressure on an already stretched service.
The dependency that a lot of participants clearly have for health services and staff was apparent during discussions regarding other aspects of the service. Some participants suggested that having their measurements taken by the AL advisor at consultation, such as blood pressure and body weight, helped them to stay motivated, and that without this they would not have stuck to their goals:
"It makes you feel more positive about it, when you've got somebody there. If you could see someone regularly you know you're going on the scales, because if you try to diet for yourself you just cheat and you're only cheating yourself."
(Female, 51 years)
Most participants found the tools such as the physical activity diaries extremely useful in helping them to stay motivated. The physical activity diary acted as a goal-planner, enabling participants to keep a record of their goals and to be able to tick them off once they had achieved them:
"They (diaries) really help me because it's like I've done that today and it did sort of remind me that well I need another walk to do ... I do 20 minutes walk 5 times a week so I used to think, right I've done 4 I'm alright, I'll go out tonight. I just stick them on my fridge."
(Female, 24 years)
"You put your goals down, like how many times you walked the dog in a week, how many you're aiming for, and then you tick them or write how much time you have done. Yes, I did (find it useful)."
(Female, 15 years)
This illustrates the potential of goal setting and self-monitoring in the maintenance of new physical activity behaviours, as has been previously highlighted by Biddle and Mutrie [
19]. Only one participant said that although she had found the diary useful initially, she had not used it after a while. The healthy eating diary also appeared to help participants to be more aware of what they were eating and drinking, and thus help them to modify their eating behaviours.
Although the AL service offers a number of venues in which to see the advisor, a few participants said that they would have preferred a greater range of options. Due to the fact that many participants relied on public transport some had found it difficult to access the service.
Some participants were aware that the AL advisor was very stretched in trying to deal with the high demand for the service, and thought that the service should be expanded and more AL advisors recruited. Despite this awareness of how busy the AL advisor was, one of the most appreciated aspects of the service was that participants felt that she had time for them, compared to their experiences of other health services, which they felt were too rushed:
"It's just that she doesn't really have time for you ... my dietician. When you go in you sit there and she goes right let's get you weighed, then she'll say right have you been following your diet, and if you say yes then she goes ok then see you in 4 to 6 weeks, and that's it ... it's more like seeing the doctor."
(Female, 24 years)
A key aspect of the AL service is that it acts as an information source and signposting service, and many of the participants had been referred from the AL service to other physical activity services. This did not always happen initially, and many participants had been supported to increase their activity levels gradually, perhaps by doing more walking and home-based activities. Later, they had been referred to other services. A few participants had merely wanted information on physical activity services such as Tai Chi classes or walking groups. Many others had been referred to the ER scheme by the AL advisor – either to the exercise classes or the gym, and some had been to both.
Overall, participants were extremely happy with the AL service, and many felt that there was little that could be done to improve it, and their main concern was that it did not cease to exist, for example due to funding cuts. Interestingly, one participant was pleased that AL was an NHS-run service:
"...knowing that the NHS was behind the scheme....it was reassuring to know that the NHS was trying to do something about it – rather than just looking after sick people they're actually trying to alter lifestyles."
(Male, 40 years)
The Active Lifestyles advisor
A crucial finding from this study was that the most important element of the AL service appeared to be the AL advisor – the personality and approach of the advisor is likely to determine the success or failure of the service. This reiterates the value of a counselling approach involving cognitive-behavioural strategies that can maximise adherence to higher physical activity levels [
20].
Overall, feedback from participants about the AL advisor was extremely positive – they were full of praise for her approach. They noted how she was caring, supportive, sincere, knowledgeable, and a good communicator and listener. Furthermore, she was genuinely interested in them as people, and provided a very personal service. This made a big impression on many of the participants, helping to boost their self-confidence and giving them a feeling that someone actually cared about them and had time to listen:
"Actually interested in you as a person, and it didn't seem like it was just a job – 'Sarah' really does care. There's an awful difference when you're doing something and just going through the motions, like 'do this' and 'do that'. She's not like that at all."
(Female, 51 years)
"I think she's a really caring person, she really wanted to help."
(Female, 37 years)
Participants appreciated the advisor's non-judgemental manner, an approach strongly encouraged by Stott and Pill [
21]. Instead, she had worked with them and helped them to make changes in a very supportive and empowering way. Rather than telling them what they should do she helped them to discover answers themselves:
"Oh yes, 'Sarah' didn't stand there with a big stick ... 'you will do this', 'you will do that', it was 'look, how do you feel about doing it?' 'how do you feel about this?' 'how do you feel about that?"
(Male, 50 years)
"She actually knew what she was talking about, she was very supportive and if you asked her a question she could answer it for you."
(Male, 40 years)
The majority of participants had greatly appreciated the gentler approach of helping them to start very slowly and build up gradually:
"She said if you're poorly and you haven't done it that week, don't feel bad about it just do it from next week. She showed me things to do even if I'm just laid up in bed, in hospital ... try and do little things."
(Female, 24 years)
By encouraging participants to progress gradually and not push themselves too much at first, the advisor also helped to dispel some of the myths about physical activity. She showed them that, as advised by Blair[
22], a low to moderate level of activity can be very beneficial and that it is not necessary to go to the gym or engage in vigorous exercise to gain health benefits:
"I thought well if you don't go to the gym it's not worth doing anything, but she proved that it's not like that."
(Female, 24 years)
Other qualities that participants appreciated in the advisor were that she was knowledgeable about the subject, and if she ever did not know something she would find out for them. They also felt that she was a good role model and was reliable, for example in returning their phone calls.
The AL advisor appears to have achieved an appropriate balance between providing a professional service but also being down-to-earth, caring, sincere and likeable at the same time:
"It is more like a friendship relationship with 'Sarah' rather than a health person, and you don't feel as though she is instructing you."
(Female, 39 years)