Physical activity referral scheme components: a study protocol for systematic review and meta-regression

Introduction In its attempt to establish effective physical activity promotion methods, research on physical activity referral schemes (PARS) is attracting significant attention. Sometimes known as physical activity on prescription schemes, PARS involve a well-defined procedure whereby a primary healthcare professional introduces a participant to the topic of physical activity and employs prescription or referral forms to connect the participant to physical activity opportunities, such as local fitness offers. The planned systematic review will focus on these referral routes and scheme components and how they are integrated into various PARS models worldwide. We seek to identify the evidence-based core components that play the most important roles in the effectiveness of PARS. Methods and analysis The development and reporting of the protocol follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We plan to conduct a systematic main literature search on PubMed, Scopus, Web of Science, CINAHL, HTA, SpringerLink and other databases. We will include studies that report outcomes on physical activity, PARS uptake and adherence rates or descriptive information about PARS models. We intend for all review stages, citation screening, data extraction and risk of bias assessment to be conducted by at least two independent reviewers. As a broad spectrum of study designs, including randomised and non-randomised studies of interventions and mixed methods, will be eligible, we will use three separate tools to assess the risk of bias in individual studies. The data will be primarily synthesised narratively, following Intervention Component Analysis. If the data allow, we will perform a random-effects meta-analysis and meta-regression to investigate the impact of specific PARS components on effect sizes. Ethics and dissemination This systematic review does not require formal ethics approval. The results will be submitted to a peer-reviewed journal and international conferences to reach the scientific community. PROSPERO registration number CRD42021233229

Development, implementation, evaluation and scaling-up of physical activity referral schemes in Germany: protocol for a study using a co-production approach

Introduction Physical activity referral schemes (PARSs) are recommended to promote physical activity (PA) among adults at risk of developing or with established non-communicable diseases (NCDs). In Germany, this kind of referral schemes has not yet been implemented systematically and nationwide. In this study protocol, we present the methodological design of a co-production research study aimed at establishing a PARS for adults with NCDs in German primary healthcare. Methods and analysis We will employ a co-production approach consistently throughout the four project phases: (1) development of the PARS; (2) preparation period; (3) implementation and evaluation; (4) development of a strategic plan for scaling up the PARS to the national level as part of standard care. The first phase will additionally include a status quo analysis of the existing physical activity pathways nationwide as well as an overview of international PARS models. A pragmatic trial design will be used for evaluating the developed PARS. The co-production approach will involve relevant actors in the German healthcare system, namely, healthcare service providers (eg, physicians, exercise professionals), health insurance providers, exercise providers, patients’ representatives, experts in the development and implementation of educational concepts, and scientists from the fields of sports science and public health. Ethics and dissemination The project has been reviewed and approved by the ethics committee of the Friedrich-Alexander-University Erlangen-Nürnberg (ethics approval number: 331_20 B). Through cooperation agreements, the stakeholders involved gave their consent to participate and were informed about the study in detail. The results of this study will be disseminated by international conference presentations and peer-reviewed publications, and if possible, a manual for the use of the PARS will be provided

Effectiveness and implementation success of a co-produced physical activity referral scheme in Germany: study protocol of a pragmatic cluster randomised trial

Background While effective physical activity referral schemes (PARSs) and related structures for promoting physical activity (PA) already exist in several countries, in Germany, PARSs have not yet been implemented systematically and nationwide. Through a co-production approach with relevant actors in the German healthcare system, a PARS was developed, and an implementation plan was created (e.g. financing). This study protocol aims to evaluate the developed PARS for people with non-communicable diseases (NCDs) in Germany regarding its potential effectiveness and implementation success. Methods To evaluate the effectiveness and implementation success of the PARS, we will apply a pragmatic cluster-randomised controlled trial (cRCT) in Hybrid II design by comparing two intervention groups (PARS vs PA advice [PAA]). The trial will take place in the Nürnberg metropolitan region, with 24 physician practices recruiting 567 people with NCDs. Both groups will receive brief PA advice from a physician to initially increase the participants’ motivation to change their activity level. Subsequently, the PARS group will be given individualised support from an exercise professional to increase their PA levels and be transferred to local exercise opportunities. In contrast, participants in the PAA group will receive only the brief PA advice as well as information and an overview of regional PA offerings to become more active at their own initiative. After 12 and 24 weeks, changes in moderate to vigorous PA and in physical activity-related health competence (movement competence, control competence, self-regulation competence) will be measured as primary outcomes. Secondary outcomes will include changes in quality of life. To measure implementation success, we refer to the RE-AIM framework and draw on patient documentation, interviews, focus groups and surveys of the participating actors (physicians, exercise professionals). Discussion Through a between-group comparison, we will investigate whether additional individual support by an exercise professional compared to brief PA advice alone leads to higher PA levels in people with NCDs. The acceptance and feasibility of both interventions in routine care in the German healthcare system will also be evaluated

S14-2: The association of physical activity referral scheme’ components with physical activity level, scheme uptake and adherence rates: a systematic review, meta-analysis with meta-regression

Purpose: Physical activity referral schemes (PARS) are complex interventions comprised of multiple components such as screening, brief advice, and written prescription. This study aimed to investigate the relationship between PARS components and physical activity, uptake, and adherence rates. Additionally, the overall effect of PARS is analysed. Methods: 6 databases were searched for studies published between 1990-2023; included PARS with participants ≥16 years old; and reported either physical activity, uptake or adherence outcomes. GRADE was used to assess quality of evidence. Separate random-effects meta-analysis by comparison group were conducted for physical activity. Uptake and adherence rates were pooled using proportional meta-analysis. The PARS components were analyzed via univariate meta-regression. Results: We included 52 studies from which 50 targeted people with, or at risk of, non-communicable diseases. PARS were compared with usual care (11 RCTs, Hedges’ g = 0.18, 95%CI 0.12 to 0.25), physical activity advice (5 RCTs, Hedges’ g=-0.6, 95%CI -0.21 to 0.10), or enhanced PARS (9 RCTs, Hedges’ g = 0.07, 95%CI -0.03 to 0.18). The pooled uptake rate was 87% (95%CI 77% to 94%) among 14 RCTs and 68% (95%CI 51% to 83%) among 14 non-experimental studies. The adherence rate across 16 RCTs and 18 non-experimental studies was 68% (95%CI 55% to 80%) and 53% (95%CI 42% to 63%) respectively. The meta-regression showed that PARS incorporating a person-centered approach, screening, and brief advice had higher adherence rates. In contrast, PARS offering physical activity sessions had lower adherence rates. No other component-outcome relationship reached statistical significance. Conclusion: High certainty of evidence confirms a small effect of PARS in increasing physical activity compared to usual care. The evidence comparing PARS with advice and enhance scheme versions is inconclusive and comes from low certainty of evidence. Four out of the 19 PARS components may predict adherence. Practical implications: The results improve our understanding of effective PARS components in relation to physical activity promotion, scheme uptake and adherence and thus support the future development of optimal PARS. Funding: The study was conducted within the project BewegtVersorgt, which is funded by the Federal Ministry of Health based on a resolution of the German ‘Bundestag’ by the federal government

Development, implementation, evaluation and scaling-up of physical activity referral schemes in Germany: protocol for a study using a co-production approach

Introduction Physical activity referral schemes (PARSs) are recommended to promote physical activity (PA) among adults at risk of developing or with established non-communicable diseases (NCDs). In Germany, this kind of referral schemes has not yet been implemented systematically and nationwide. In this study protocol, we present the methodological design of a co-production research study aimed at establishing a PARS for adults with NCDs in German primary healthcare.Methods and analysis We will employ a co-production approach consistently throughout the four project phases: (1) development of the PARS; (2) preparation period; (3) implementation and evaluation; (4) development of a strategic plan for scaling up the PARS to the national level as part of standard care. The first phase will additionally include a status quo analysis of the existing physical activity pathways nationwide as well as an overview of international PARS models. A pragmatic trial design will be used for evaluating the developed PARS. The co-production approach will involve relevant actors in the German healthcare system, namely, healthcare service providers (eg, physicians, exercise professionals), health insurance providers, exercise providers, patients’ representatives, experts in the development and implementation of educational concepts, and scientists from the fields of sports science and public health.Ethics and dissemination The project has been reviewed and approved by the ethics committee of the Friedrich-Alexander-University Erlangen-Nürnberg (ethics approval number: 331_20 B). Through cooperation agreements, the stakeholders involved gave their consent to participate and were informed about the study in detail. The results of this study will be disseminated by international conference presentations and peer-reviewed publications, and if possible, a manual for the use of the PARS will be provided

A systematic review and narrative synthesis of physical activity referral schemes’ components

Background: Physical activity referral schemes (PARS) are complex multicomponent interventions that represent a promising healthcare-based concept for physical activity (PA) promotion. This systematic review and narrative synthesis aimed to identify the constitutive components of PARS and provide an overview of their effectiveness. Methods: Following a published protocol, we conducted a systematic search of Pub Med, Scopus, Web of Science, CINAHL, ScienceDirect, SpringerLink, HTA, Wiley Online Library, SAGE Journals, Taylor & Francis, Google Scholar, OpenGrey, and CORE from 1990 to January 2023. We included experimental, quasi-experimental, and observational studies that targeted adults participating in PARS and reported PA outcomes, scheme uptake, or adherence rates. We performed an intervention components analysis using the PARS taxonomy to identify scheme components and extracted data related to uptake, adherence, and PA behavior change. We combined these to provide a narrative summary of PARS effectiveness. Results: We included 57 studies reporting on 36 PARS models from twelve countries. We identified 19 PARS components: a patient-centered approach, individualized content, behavior change theory and techniques, screening, brief advice, written materials, a written prescription, referral, baseline and exit consultation, counselling support session(s), PA sessions, education session(s), action for nonattendance, structured follow-up, a PA network, feedback for the referrer, and exit strategies/routes. The PARS models contained a mean of 7±2.9 components (range = 2–13). Forty-five studies reported PA outcome data, 28 reported uptake, and 34 reported adherence rates. Of these, approximately two-thirds of studies reported a positive effect on participant PA levels, with a wide range of uptake (5.7–100.0%) and adherence rates (8.5–95.0%).Conclusions: Physical activity referral scheme components are an important source of complexity. Despite the heterogeneous nature of scheme designs, our synthesis was able to identify 19 components. Further research is required to determine the influence of these components on PARS uptake, adherence, and PA behavior change. To facilitate this, researchers and scheme providers must report PARS designs in more detail. Process evaluations are also needed to examine implementation and increase our understanding of what components lead to which outcomes. This will facilitate future comparisons between PARS and enable the development of models to maximize impact

Are physical activity referral scheme components associated with increased physical activity, scheme uptake, and adherence rate? A meta-analysis and meta-regression

Background: Physical activity referral schemes (PARS) are composed of various components, such as a written prescription or a person-centered approach. The role of these components in their effectiveness is yet to be understood. Therefore, we aimed to explore the relationships between PARS components and physical activity, scheme uptake, and adherence rate; and to estimate the effect of PARS.Methods: We searched Scopus, PubMed, Web of Science, CINAHL, ScienceDirect, SpringerLink, HTA, Wiley Online Library, SAGE Journals, Taylor & Francis, Google Scholar, OpenGrey, and CORE. Eligible studies were published between 1990 and November 2023 in English or German, investigated PARS with participants aged ≥16 years, and reported physical activity, scheme uptake, or scheme adherence. Separate random-effects meta-analysis by comparison group were conducted for physical activity. Scheme uptake and adherence rates were pooled using proportional metaanalysis. The components were analyzed via univariate meta-regression. We rated the risk of bias using RoB2 and ROBINS-I, and the certainty of the evidence using GRADE.Results: Fifty-two studies were included. PARS were more effective in increasing physical activity than usual care (k=11, n=5046, Hedges’ g=0.18, 95%CI 0.12 to 0.25; high certainty of evidence). When PARS were compared with physical activity advice or enhanced scheme versions, the pooled Hedges’ g values for physical activity were - 0.06 (k=5, n=1082, 95%CI -0.21 to 0.10; low certainty of evidence), and 0.07 (k=9, n=2647, 95%CI -0.03 to 0.18; low certainty of evidence) = respectively. Scheme uptake was 87% (95%CI 77% to 94%, k=14, n=5000) across experimental studies and 68% (95%CI 51% to 83%, k=14, n=25,048) across non-experimental studies. Pooled scheme adherence was 68% (95%CI 55% to 80%, k=16, n=3939) and 53% (95%CI 42% to 63%, k=18, n=14,605). The meta-regression did not detect any significant relationships between components and physical activity or scheme uptake. A person centered approach, screening, and brief advice were positively associated with scheme adherence, while physical activity sessions were negatively associated.Conclusion: PARS are more effective in increasing physical activity than usual care only. We did not identify any components as significant predictors of physical activity and scheme uptake. Four components predicted scheme adherence, indicating that the component-effectiveness relationship warrants further research