The study was conducted in primary health care (PHC) in the county of Östergötland, Sweden, in the year 2004. This county of 416,000 inhabitants is the fourth largest county in Sweden and includes two large cities (> 120,000 inhabitants) and 11 smaller, more rural municipalities. At the time of the study, the County Council encompassed three hospitals and 42 PHC centres, of which four were privately owned and 38 were managed by the County Council.
All PHC centres in Östergötland have a specified catchment area and/or a listed population (ranging from 3,700 to 20,700 patients per unit). The PHC centres usually include different health care professionals, i.e. physicians, nurses, physiotherapists, occupational therapists, dieticians, and behavioural scientists. The number of staff in the PHC centres ranged from 10 to 80, with the number of physicians ranging from 2 to 12 and nurses from 8 to 35 (as of 31 December 2004).
The PAR scheme in Östergötland was built on structures developed over a number of years, based on collaborations between local physical activity organizations and PHC centres. This included the development of a widely used locally adapted prescription form, information materials, and knowledge exchange among the actors involved.
At the end of 2003, 80% of the PHC centres in the region worked with PARs to some extent and had established a supportive community-based structure to assist patients to gain access to various local activities.
Ethical approval was not required for this follow-up as the data collection was part of the routine health care system.
The prescription procedure
The prescription procedure was intended to be patient-centred, and to take into consideration the patient's current activity level, activity history, capacity, motivation, and interests. Persons eligible to receive PARs were all ordinary PHC patients whom the regular staff believed would benefit from increased physical activity. Swedish PARs consist of activities that are home-based and/or self-monitored, such as walking, jogging or cycling, and facility-based activities organised by different physical activity organisations in the community. The patients either had a sedentary lifestyle or a diagnosis that indicated that increased physical activity could be beneficial, e.g. high blood pressure, diabetes, and/or musculoskeletal disorders.
The patient was provided with a written PAR and a copy was kept in the patient's medical record. If the activity prescribed was facility-based (e.g. group gymnastics, aerobics, water aerobics, weight and circuit training.), a copy was also sent to the PARs coordinator in the relevant physical activity organization, who then contacted the patient by telephone or letter. The patients paid the normal fee to the organization they attended. The physical activity organization also made a phone call after 5 weeks to verify if the patient had attended the suggested group activity. The purpose of the phone call was threefold: (1) to guide and motivate potential drop-out patients to participate in other activities; (2) to give other patients/participants the opportunity to attend instead of drop-out patients; (3) and to gather information about drop-outs for feedback to the PHC centres. Patients who were prescribed home-based activities, such as walking, did not receive this phone call.
Patients were recruited prospectively from 37 of the 42 PHC centres in the county. Of the five centres that did not participate, two were public PHC centres that did not work with PARs and three private PHC centres declined to participate due to lack of time. A 3-month follow-up on patients issued physical activity on prescription was conducted by 36 centres and a 12-month follow-up was conducted by 27 centres. The main reasons for non-participation in follow-ups by PHC centres were lack of time or shortage of staff.
All prescription forms were registered by the PARs coordinator in each unit in a Microsoft Excel spreadsheet, which was sent to the first author three times a year.
Follow-up measures were performed by PHC personnel. Three different methods were used to collect the questionnaire data: telephone interview, postal questionnaire, and/or questionnaire provided during the patient's normal return visit. At the 3-month follow-up, 74% of the patients were contacted by telephone, 14% by postal questionnaire, and 12% answered the follow-up questions during a return visit. The 12-month follow-up showed a similar pattern with 68% contacted by telephone, 21% by postal questionnaire, and 11% during a return visit.
The prescription form used to collect the baseline data included patient data such as age, sex, address, telephone number, and information about the prescriber's profession.
Patients were asked to state the number of days in the previous week (7-day recall) "with at least a total of 30 minutes of physical activity that made you warm, e.g. brisk walking, gardening, heavy housework, cycling and/or swimming". This short and simple question was used for practical reasons, and was based on the current physical activity recommendation in Sweden. In the analysis, the patients' self-reported physical activity was classified into four groups: (1) regularly active (those who reported 5-7 days of 30 minutes of moderately intense physical activity); (2) moderately active (3-4 days); (3) somewhat active (1-2 days); and (4) inactive (0 days). Data including additional baseline data and data regarding physical activity level before and after the intervention are presented elsewhere.
Reasons for receiving PARs were registered on the prescription form by selecting one or more of seven predefined options including sedentary lifestyle. The disease-specific options were musculoskeletal disorders, overweight (body mass index > 25), diabetes, high blood pressure, high blood cholesterol, and mental ill-health. The "other PARs reasons" included asthma and chronic pulmonary disease. Patients issued prescriptions for more than one reason were categorized as "combination of reasons/diagnoses".
The activities could either be home-based (free-living or lifestyle activities such as walking) or structured facility-based provided by a local physical activity organization. Patients who were issued home-based activities and structured facility-based activities were classified into a combination category.
Follow-up measures at 3 and 12 months
The patients' self-reported adherence to the issued activity was measured by asking the patient the question "have you adhered to your physical activity prescription?" The respondent selected one of three alternatives: (1) "I adhered to the prescription"; (2) "I'm active but in another activity than the prescribed activity"; (3) "I do not follow my prescription". Results are presented as (1) adhered, (2) partly adhered, and (3) non-adhered. Follow-ups also included the same physical activity question, and the patients were asked to state their current physical activity, data presented elsewhere .
In the descriptive analyses, differences between proportions were analysed with the non-parametric chi-square test.
Univariate and multiple logistic regression analyses were applied to identify possible associations between self-reported adherence, and sex, age, activity level at baseline, referred activity type, referral practitioner, and reason for prescription of physical activity. Separate analyses were done for the 3- and 12-month follow-ups. As the aim of the study was to analyse adherence, patients reporting part adherence were excluded from these analyses, e.g. outcome measure was adhered vs. not adhered. All variables with a p-value < 0.2 in the univariate logistic analyses were included in the multiple logistic regression analyses. In the two final multiple models, all possible two- and three-way interaction terms were tested.
Statistical significance was set at p < 0.05 and the confidence interval was 95%. SPSS (release 15.0) software was used for all analyses.