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clinmed/2004060001v1 (June 29, 2004)
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STRATEGIES TO INCREASE PHYSICAL ACTIVITY IN THE COMMUNITY
There have been many different interventions at the community level to encourage people to become more physically active. A review of the published literature by Kahn et al (2002) defined three types of community intervention to increase physical activity: Informational approaches, behavioural and social approaches and environmental and policy approaches (Table 2). Informational approaches aim to increase physical activity by providing information that will motivate people to change their behaviour. These approaches often complement the medical model of disease management, for instance by supporting the management of cardiovascular disease. Behavioural and social approaches are often based on health promotion models in order to change individual and group behaviour. These interventions appear to be more effective in younger children and in a family setting than when provided within a school setting. Finally, environmental and policy approaches intend to increase opportunities for physical activity by providing gym facilities or activities in which to participate. Exercise referral schemes, which are becoming increasingly popular in the UK, are an example of this type of intervention.
Although there is evidence that some of these interventions may be effective at increasing levels of physical activity, it is not clear whether these gains are maintained in the longer term or result in better health outcomes. Unfortunately, many of these studies report interventions that are too intensive to be reproduced in a service setting and few consider their cost effectiveness. Disappointingly, physical activity interventions appear to be least effective amongst the least active individuals. However, increasing physical activity in this group would provide the greatest public health gain.
The majority of people in the UK do not take enough exercise. The effect on health is all too apparent when we consider the burden of obesity, type II diabetes and cardiovascular disease; lack of physical activity should be considered as great a threat to health as smoking. There is strong evidence that partaking in at least 30 minutes of physical activity on five or more occasions per week can prevent and reverse/manage conditions associated with physical inactivity. However, the evidence for community-based interventions is much weaker.
This presents a dilemma for public health practitioners – we know that physical activity is good for health, but we don’t know how to get people in the community to become more active. For example, the National Service Framework for Coronary Heart Disease recommends physical activity as a preventative measure, but does not address the lack of evidence-based interventions with which to achieve this. In 2001, the Department of Health published a guidance document Exercise Referral Systems: A National Quality Assurance Framework. However, the document is notable for an almost complete lack of evidence to support its guidelines. In order to address this gap in the evidence, a £2.6 million initiative called LEAP (Local Exercise Action Pilots) was launched by the Department of Health, the Countryside Agency and Sport England. Nine Primary Care Trusts will introduce and evaluate a range of interventions over a two-year period. However, it is unclear whether sufficient resources will follow to fund other PCTs to develop similar programmes.
Limited evidence for effective community-based approaches presents a significant challenge for public health professionals in Primary Care Trusts. In an environment under pressure to achieve targets within a limited budget, programmes without good evidence of effectiveness are often a ‘hard sell’. Nevertheless, with the majority of people not taking enough exercise and such strong evidence that physical inactivity is bad for health, it would be imprudent for Primary Care Trusts to not act.
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