Context analysis in the development for future implementation of exercise is medicine® initiative as prevention and treatment resource for chronic diseases at primary healthcare settings

Resumen

The current Ph.D. thesis is based on the Exercise is Medicine® initiative of the American College of Sports Medicine (ACSM), regarding the use of physical activity (PA) as a preventive resource and exercise prescription as a non-pharmacological adjuvant resource in Primary Health-Care (PHC) settings. The results of this Ph.D. thesis have a social, scientific and health interest for the community and could be used by the Healthcare System as a cost-effectiveness resource. Physical inactivity and sedentary patterns currently represent one of the major threats to public health with pessimistic perspectives for the future. Approximately one-third of the population has insufficient PA behaviours. Many strategies have been developed regarding health promotion since the Ottawa Charter in 1986. Currently, the "WHO Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013–2020" and the "PA strategy for the World Health Organization (WHO) European Region 2016–2025", are trying to increase PA levels in the population, including PA on prescription at healthcare settings. The WHO target is to reduce physical inactivity levels by 15% in 2030 worldwide by the "Global action plan on physical activity 2018–2030: more active people for a healthier world". The main objective of this Ph.D. thesis is: To analyze the feasibility of physical activity on prescription (PAP) implementation as a preventive and treatment resource for non-communicable chronic diseases in PHC settings. Secondary objectives are: (1) To analyze the inclusion of PA and exercise as a preventive and treatment resource for chronic diseases in the syllabus of Bachellors in Medicine, Sports Science and Nursing at Spanish universities. (2) To review studies which have reported adherence to exercise prescribed to chronic patients, according to the WHO multi-dimensional adherence model. (3) To analyze exercise training programmes adherence in dialysis patients. (4) To analyze in depth attitudes, self-perception, barriers, facilitators and knowledge of nurses and physicians towards the implementation of PAP at Madrid PHC settings. (5) To compare PA and sedentary patterns, measured objectively (by accelerometer) or subjectively (by the PAVS-EIM and the IPAQ short version questionnaires), for contributing to the design of a patient anamnesis tool at PHC centers. The main outcomes of this Ph.D. thesis are: a) ECTS regarding physical activity promotion and exercise prescription in the Bachelor syllabus at Spanish universities are for Sport Sciences 17.7±4.6%, Nursing 5.8±3.9% and Medicine 3.6±1.7%. b) In the reviewed literature, adherence to exercise prescriptions was mainly related to the social/economical dimension (97 factors), followed by condition-related dimension (59 factors) and patient-related factors (n=58). Dimension related to Healthcare team and System was less cited with only 20 factors. c) In chronic kidney patients, 75% of exercise training programme adherence (attendance to at least 75% of 40 total sessions scheduled) was 33.20% predicted with our logistic regression model when considering all the dimensions together. The increase in one unit of the Therapy-related dimension (measured by symptoms/problems, KDQOL™-36 test) increases 7.8% of non-adherence. The increase in one unit of the Condition-related dimension (measured by BECK depression test) increases the probability of non-adherence in 11.8%. The increase in one unit of the Patient-related dimension (measured by Emotional well-being, KDQOL™-36 test) increases 4.6% of adherence. Finally, an increase in one unit of the Patient-related dimension (measured by Self-perceived State-Anxiety, STAI test) increases the probability of adherence in 12.2%. d) Two choice modelling questionnaires had been designed for physicians (https://goo.gl/forms/zkygjoULFoBYRWwR2) and for nurses (https://goo.gl/forms/t3xsHage6k8E0rXv2) according to the self-perception barriers shown by a randomized sample of PHC nurses and physicians chosen in the focus groups sessions developed. e) The two choice modelling questionnaires were validated by a group of ten experts each, with Aiken’s V coefficient values of 0.84 and 0.89 for physicians and nurses questionnaire, respectively. f) Almost 100% of PHC professionals admitted health preventive benefits of PA and exercise, although, 24.3% to 37.0% of respondents, considered it only for some adult age range and sex. Only 14.7% of GPs knew current WHO PA guidelines, in contrast to 75.7% of nurses. In spite of the lack of PA guidelines knowledge of some PHC professionals, more than 80.15% (78.1% GPs and 82.8% nurses) recognized to be physically active. According to the Transtheorical model of change in human behavior, more than 79.5% PHC staff (81.5% GPs and 77.5% nurses) indicated to maintain the PAP routine with their patients since more than 6 months. PHC staff was more confident in the self-perception knowledge to promote PA 70.85%, (71.5% GPs and 70.2% nurses) than to prescribe exercise 39.8%, (44.2% GPs and 35.4% nurses, p= 0.02). A mean of 63.2% (62.3% in PA promotion and 64.2% in exercise prescription) of PHC professionals assessed, agree to the collaboration with Sports Scientists for PAP. The 98.0% of both PHC professionals showed total agreement to collaborate with other PAP community resources from the PHC System. Moreover, there were some discrepancies between PHC staff assessed in the community resources proposed. Categorized by PHC areas, they totally agree in Sport and Younger Government, Private Gyms collaboration. However, they are significant differences in the collaboration with Town Hall services (p<0.001), Local Sports centers (p<0.001), Schools (p<0.05), Physiotherapy and Wellness centers (p<0.001). 57.6% of PHC respondents had never done previous PA promotion courses (63.0% GPs and 52.3% nurses, p= 0.006). 70.4% of all PHC professionals showed no academic training background in exercise prescription (72.4% GPs and 68.4% nurses). The 94.95% of the respondents (93.4% GPs and 96.5% nurses) are interested in PAP training courses. Significant differences were found for GPs and nurses in the following barriers: lack of space (p<0.05); lack of time-management (p<0.05). And total agreement for the following barriers: lack of PHC professional awareness, lack of material and economic resources; lack of PAP awareness in patients, lack of use and collaboration with another public external PAP resources. For the multi-choice solutions proposed for GPs and nurses, discrepancies were observed in the improvement of PAVS tool for anamnesis (p<0.001); specific PHC spaces for PAP (p<0.001); materials and economic resources improvements (p<0.001); PAP leader at PHC (p=0.006); PAP use of the first-time visit at PHC (p<0.05); collaboration with another public external resources (p=0.002). In addition, PAP Networking team, PAP Training courses, PAP Diffusion strategies, Progressive PAP Implantation and to increase Consultation Time are the solutions with maximum consensus among both PHC professionals (with more than 90.0% of agreement). g) PA and sedentary patterns measured by the PAVS-EIM, the IPAQ short version questionnaires and the accelerometer data register, depending of the place position, frequency, epoch register and cut-off points values chosen in the raw processing data, showed high inter and intra-variability for the 7 days sedentary (p<0.05) and physical activity levels (PAL) registered. This holistic and novel approach can contribute to establish PA public health policies and new interventions in PHC settings.