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

Abstract

Background: Increasing levels of physical activity decreases the risk of premature mortality associated with chronic diseases e.g., coronary heart disease, type 2 diabetes, stroke. Despite this, most adults in England do not meet physical activity guidelines. Physical activity advice and signposting offered to at-risk patients by primary care providers is recommended. However, exercise medicine education is sparse, leading to poor practitioner knowledge of the risk reduction evidence and strategies to implement effective patient behaviour change. The 'Generation Games' intervention seeks physical activity increase in the 50+ population of Oxfordshire. It offers a Health Professional Education Programme (HPEP) providing exercise medicine education, and promotion of Generation Games to which health professionals can signpost patients. There is a poor evidence base concerning how such education translates into patient exercise behaviour change.

Methods: The research aimed to create more understanding of how an education programme can influence health professionals to recommend Generation Games to and increase exercise behaviour in type 2 diabetes patients. A case study method facilitated examination of the routines and cultures studied - the experience of Diabetes nurses was used as an example of best practice engagement with the HPEP. Observation, interviews and documentation were employed to triangulate data. Data analysis refined and developed themes within key theoretical frameworks.

Results: Firstly, there is a lack of knowledge about physical activity risk reduction benefits and a belief that efforts to motivate patients to increase their physical activity are ineffective, thus creating barriers to engagement with the HPEP. Secondly, practice nurses tasked with delivering lifestyle advice to diabetes patients - themselves suffering a motivational interviewing skill deficit - find ingrained physical activity behaviours extremely challenging, and therefore highly value the HPEP for providing helpful tools. Thirdly, patients who hear of Generation Games from a health professional may have mismatched expectations of how their exercise behaviour can change.

Conclusions: Exercise medicine education has the potential to improve patient care and services. Before initiatives like the HPEP can succeed, primary care practice requires a more supportive exercise medicine culture. Also necessary is adequate resourcing of patient-centred behaviour change advice, training, encouragement and monitoring services.

Keywords: Behaviour change; Exercise; Health professional; Medical education; Type 2 diabetes.

Fig. 1

Flowchart showing pathway of behaviours necessary to ‘reach’ a Generation Games participant

Fig. 2

Flowchart showing Generation Games Health Professional Education Programme

Fig. 3

Flowchart showing four aspects central to the HPEP concept of patient ‘reach’, and three theoretical models used for data analysis

Fig. 4

Health Belief model including findings showing nurses beliefs about patient attitudes to physical activity

Fig. 5

Theory of Planned Behaviour model including findings showing how cultural norms influence expectation and nursing practice

Fig. 6

Self Determination Theory model including findings relating to competence, relatedness and autonomy which affect motivation

Fig. 7

Model of good practice for improving physical activity promotion to chronically ill older patients within primary and secondary healthcare settings