The MoXFo initiative - adherence: Exercise adherence, compliance and sustainability among people with multiple sclerosis: An overview and roadmap for research.

We know very little about exercise adherence, compliance and sustainability in multiple sclerosis (MS), yet adherence is seemingly important for yielding immediate and sustained health benefits. This paper is focused on exercise adherence, compliance and sustainability in the context of informing research and practice involving MS. This focus is critical for clarifying terminology for future research and providing a roadmap guiding clinical research and practice. Our objective was accomplished through a narrative summary of the literature by a panel of experts on exercise adherence from the Moving Exercise Research in Multiple Sclerosis Forward (MoXFo) initiative and a concluding summary of the state of the literature and future research directions. The panel of experts identified three overall themes (Background and Importance; Understanding and Promoting Exercise Adherence, Compliance and Sustainability and Challenges to Exercise Adherence, Compliance and Sustainability) that represented a categorization of nine subthemes. These overall themes and subthemes formed the basis of our recommendations regarding future research broadly involving exercise adherence in MS. Overall, there is limited evidence on rates and determinants of exercise adherence and compliance in MS, and little is known about techniques and interventions for immediate and long-term exercise behaviour change.

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 PubMed, 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 non-attendance, 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.

Population-based physical activity promotion with a focus on health equity: a review of reviews.

BACKGROUND: The extent to which people are physically active is dependent upon social gradients. Numerous studies have shown that especially people with social disadvantages do not meet the physical activity (PA) recommendations. A promising strategy to alleviate this issue are approaches that promote PA in the general population. In addition, several researchers have raised concerns that population-based health interventions may increase health inequities. The aim of the current review of reviews was therefore to identify successful population-based PA promotion approaches with a particular focus on health equity. METHODS: Six electronic databases were examined for systematic reviews on population-based PA promotion for the period 2015 to 2021. A reference list and grey literature search were also conducted. Two independent reviewers used inclusion/exclusion criteria to screen titles and abstracts of the potentially relevant literature and conducted a quality assessment for each identified review. All included reviews of population-based approaches for PA promotion with a focus on disadvantaged populations and/or health equity were narratively summarized. RESULTS: Our search resulted in 4,411 hits. After a systematic review process, six reviews met the inclusion criteria and were included after they were all rated as high quality. We identified that mass-media campaigns, point-of-decision prompts, environmental approaches, policy approaches, and community-based multi-component approaches can promote PA in the general population. Across populations with social disadvantages mass-media campaigns, point-of-decision prompts and policy approaches are likely to be effective as long as they are tailored. Regarding environmental approaches, the results are inconsistent. None of the reviews on community-based multi-component approaches provided evidence on health equity. CONCLUSION: There are several effective approaches to promote PA in the general population but evidence regarding health equity is still sparse. Future studies should therefore pay more attention to this missing focus. Furthermore, there is a lack of evidence regarding the type of tailoring and the long-term impact of population-based approaches to PA promotion. However, this requires appropriate funding programmes, complex study designs and evaluation methods.

Multi-level stakeholders' perspectives on implementation and scaling up community-based health promotion in Germany.

Community-based health promotion has the potential to address existing health inequities, although such approaches are scarcely scaled up. For a successful scale up, various stakeholders at different levels and sectors need to be involved. The article's aims are to assess what kind of external support communities need for implementation and to identify facilitators and barriers for scaling up community-based health promotion. Two national digital workshops were conducted in Germany with stakeholders at the community level (n = 161) and with stakeholders at the federal and state levels (n = 84). Protocols were compiled and coded using qualitative content analysis. During the first workshop, we revealed 11 themes for external support needs ('Strategic approach', 'Define & compare indicators', 'International human resource', 'Tools & Aids', 'External conduction of the assessment', 'Involvement of people in difficult life situations', 'Overview of actors', 'Moderation', 'Obtain funding', 'Quality assurance/evaluation' and 'External support'). Eleven facilitators and barriers were identified for scaling up ('Assessment and evaluation', 'Intersectoral collaboration and partnerships', 'Communication', 'Characteristics of the program', 'Political and legal conditions', 'Political support', 'Local coordinator', 'Resources', 'Participation', 'Strategic planning/methods' and 'Intermediary organization'). The identified results provide practice-based evidence on support needed for scaling up, facilitators that promote scaling up and barriers that might hinder scaling up community-based health promotion in Germany. In a next step, this practice-based evidence needs to be systematically integrated with scientific-based evidence on key components for scaling up such approaches for the development of an effective scaling-up concept.

The major aim of this article is to describe how German stakeholders at different levels (local, federal and state) from various sectors (e.g. health, social or sports) were involved to develop a scaling-up concept for a community-based health promotion approach with a focus on health equity in the field of physical activity promotion. Different actors from science, policy and practice discussed facilitators and barriers for the scale up and what external support communities need to implement a community-based health promotion approach, with a focus on people in difficult life situations (e.g. individuals with social disadvantages). We identified 14 different kind of support needs and 11 facilitators and barriers for scaling up community-based health promotion approaches in the field of physical activity promotion. Various actors emphasized the need for improved collaboration and partnerships across several sectors as well as changes in current political and legal conditions. Furthermore, the role and some characteristics of an external organization to support a successful scaling-up process were also discussed among actors.

[Perspective Paper "Future Prevention Research" - Current and Future Coordinated Research on Prevention and Health Promotion]. / Perspektivpapier "Zukunft Präventionsforschung": Koordinierte Forschung zu Prävention und Gesundheitsförderung ­ aktuell und in der Zukunft.

From 2014 to 2022, the BMBF has funded five research networks in prevention research and health promotion that are also jointly coordinated (Research Network Primary Prevention and Health Promotion, www.fp2g.net). The researchers have produced a large number of relevant research outputs with insights gained into essential aspects of prevention research and health promotion. The networks research focused on basic principles, application-relevant findings, and implementation conditions of long-term prevention and health promotion for non-communicable diseases (NCDs). The constraints imposed by the pandemic from 2020 onwards were partly addressed by integrating Corona-related research and transfer activities. The importance of resilience for dealing with multiple health and social challenges got increased attention and was analyzed and discussed during the pandemic. For prevention research, research questions such as how to better implement prevention measures through digital tools are gaining additional importance. Together, the research networks have presented achievements and desiderata for future research. This perspective paper with its nine theses formulated in conclusion is intended as a stimulus for discussion among funders as well as the communty of researchers on the subject of successful prevention and health promotion. It is explicitly part of the continuity of the memoranda on prevention research developed in 2012.

Examining the sustainability and effectiveness of co-created physical activity interventions in vocational education and training: a multimethod evaluation.

BACKGROUND: Co-creation approaches are increasingly used in physical activity promotion to develop interventions tailored to the target group and setting. The resulting complexity of such interventions raises challenges in evaluation. Accordingly, little is known about the effectiveness of co-created interventions and the underlying processes that impact their sustainable implementation. In this study, we attempt to fill this gap by evaluating co-created multi-component physical activity interventions in vocational education and training in nursing care and automotive mechatronics regarding (1) their sustainable implementation at the institutional level and (2) the effectiveness of single intervention components at the individual level. METHODS: Following a multimethod design, we conducted a questionnaire survey (n = 7) and semi-structured interviews (n = 4) to evaluate the sustainability of the interventions. Quantitative data were analyzed descriptively, and qualitative data were analyzed using qualitative content analysis. To examine the interventions' effectiveness, we conducted two non-randomized controlled trials (n = 111). Analysis of variance was used to examine differences between groups. RESULTS: At the institutional level, long-term implementation of single intervention components in nursing care was observed; in contrast, long-term implementation in automotive mechatronics was not observed. In this context, various factors at the outer contextual (e.g., COVID-19 pandemic), inner contextual (e.g., health-promoting leadership), intervention (e.g., acceptance), and personal levels (e.g., champion) influenced sustainability. At the individual level, no significant intervention effects were found for changes in physical activity behavior and physical activity-related health competence. CONCLUSION: The role of co-creation on the effectiveness and sustainability of physical activity promotion in vocational education and training cannot be answered conclusively. Only in the nursing care sector, a co-creation approach appeared promising for long-term intervention implementation. Sustainable implementation depends on various influencing factors that should be considered from the outset. Demonstrating effectiveness at the individual level was challenging. To conclusively clarify both the role and impact of co-creation, methodologically complex and elaborate evaluation designs will be required in future research projects. TRIAL REGISTRATION: This study was retrospectively registered at clinicaltrials.gov on 24/08/2021 ( NCT05018559 ).

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. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04947787 . Registered 01 June 2021.

The Relevance of Competences for a Healthy, Physically Active Lifestyle in Persons with Multiple Sclerosis: a Path Analytical Approach.

To promote health and counteract the decline associated with the disease, persons with multiple sclerosis (pwMS) are advised to lead healthy, physically active lifestyles. The physical activity-related health competence (PAHCO) model posits that individuals must meet three integrated, person-related requirements for the adoption of such a lifestyle: movement competence, control competence, and self-regulation competence. To gain insights into the needs and challenges of pwMS, the goal of the present study was to empirically examine the roles of these competences within this target group. A total of 475 pwMS underwent a multidimensional, online-based assessment of PAHCO. These participants self-reported their amount of physical activity (PA), health status, disease-related, and sociodemographic information. We used a series of path analyses to investigate the relevance of the three competence areas for each individual's PA level and subjective health. Stepwise multivariate analyses revealed that self-regulation competence was significantly associated with overall PA volume. In contrast, movement competence did not contribute to this prediction. Control competence was also not related to PA level. However, in accordance with the PAHCO model, this factor exerted an independent, qualitative effect on participant health. In summary, self-regulation competence appears to play a crucial role with regard to PA volume. Specifically, control competence appears to be key for the qualitative aspect of PA promotion, characterizing the individual's application of an appropriate stimulus for the achievement of health. Integrating the promotion of self-regulation and control competences into rehabilitation practices can help to foster healthy, physically active lifestyles in pwMS.Supplemental data for this article is available online at https://doi.org/10.1080/08964289.2021.1935437 .

[Dissemination of National Physical Activity Recommendations: Participatory Development of Dissemination Strategies in Germany]. / Disseminierung der Nationalen Bewegungsempfehlungen: Partizipative Entwicklung von Disseminierungsstrategien in Deutschland.

BACKGROUND: In 2016, the first evidence-based National Recommendations for Physical Activity and Physical Activity Promotion were published in Germany. These recommendations are primarily intended for experts, decision makers and stakeholders. OBJECTIVES: This study aims to describe the development of dissemination strategies for these recommendations. PROCESS: To facilitate the co-production of knowledge between practitioners, decision makers, and researchers, a participatory approach was applied. This approach involved the development of target group-specific strategies for disseminating the recommendations. This was achieved in two workshops and one working group phase; 92 professionals and decision makers participated in the process. RESULTS: The working groups developed specific dissemination strategies that were grouped into the following strategy types: (1) inform multipliers, (2) activate multipliers, (3) use existing and develop new networks, (4) initiate policy change. CONCLUSION: The participatory approach adopted in this project was successful in developing dissemination strategies and is unique from an international perspective. To improve the evaluation of such co-production processes, future research should determine and operationalize appropriate indicators.

[Physical Activity Promotion in Exercise Therapy in Medical Rehabilitation: Consequences of the Nationwide Survey for Quality Development]. / Bewegungsförderliche Bewegungstherapie in der medizinischen Rehabilitation: Konsequenzen der bundesweiten Bestandsaufnahme für die Qualitätsentwicklung.

AIM: This article aims to summarize the status quo of exercise therapy in medical rehabilitation with regard to the establishment of the biopsychosocial understanding of health with a special focus on physical activity promotion; based on this, consequences for the optimization of exercise therapy are derived. METHODOLOGY: A three-step procedure was chosen, which builds on the elaboration of quality dimensions and quality-relevant areas of physical activity promotion in exercise therapy: 1.) the analysis of the current status quo of exercise therapy with regard to the quality-relevant characteristics. This is based on the current results from the project "Exercise therapy in medical rehabilitation: a national survey at facility and practitioner level" (BewegtheReha); 2.) the elaboration of optimization potential and 3.) the derivation of consequences for the systematic quality development of exercise therapy. RESULTS: We analyzed the status quo of exercise therapy for the following areas: Assessment and information gathering, targets and impact areas, therapeutic contents, working methods and implementation, therapy control as well as allocation to exercise therapy (step 1). The results show that the physical activity promoting potential of exercise therapy within medical rehabilitation has not yet been optimally exploited. In particular, there is a need for more interdisciplinarity, more patient orientation, therapeutic work on the basis of theory- and evidence-based biopsychosocial therapy concepts with stronger manualization and standardization (step 2). Starting points for quality improvement can be found at the therapist level as well as at the program level and the system level. The derived recommendations for quality improvement of physical activity promotion in exercise therapy (step 3) refer to three levels: a) human resource development, e. g. with regard to improved use and quality of the education system, b) organizational development, e. g. promotion of interprofessional cooperation, and c) provision of resources, e. g. access to information. CONCLUSION: The derived consequences form the basis for the systematic further development and optimization of physical activity in exercise therapy in the context of medical rehabilitation. Based on the results, next steps for improving quality of exercise therapy with a focus on the goal of physical activity promotion can be identified and initiated.

Acute exercise following skill practice promotes motor memory consolidation in Parkinson's disease.

Acute cardiovascular exercise has shown to promote neuroplastic processes supporting the consolidation of newly acquired motor skills in healthy adults. First results suggest that this concept may be transferred to populations with motor and cognitive dysfunctions. In this context, Parkinson's disease (PD) is highly relevant since patients demonstrate deficits in motor learning. Hence, in the present study we sought to explore the effect of a single post-practice exercise bout on motor memory consolidation in PD. For this purpose, 17 patients with PD (Hoehn and Yahr: 1 - 2.5, age: 60.1 ± 7.9 y) practiced a whole-body skill followed by either (i) a moderate-intense bout of cycling, or (ii) seated rest for a total of 30 min. The motor skill required the participants to balance on a tiltable platform (stabilometer) for 30 s. During skill practice, participants performed 15 trials followed by a retention test 1 day and 7 days later. We calculated time in balance (platform within ± 5° from horizontal) for each trial and within- and between-group differences in memory consolidation (i.e. offline learning = skill change from last acquisition block to retention tests) were analyzed. Groups revealed similar improvements during skill practice (F4,60 = 0.316, p = 0.866), but showed differences in offline learning, which were only evident after 7 days (F1,14 = 5.602, p = 0.033). Our results suggest that a single post-practice exercise bout is effective in enhancing long-term motor memory consolidation in a population with motor learning impairments. This may point at unique promoting effects of exercise on dopamine neurotransmission involved in memory formation. Future studies should investigate the potential role of exercise-induced effects on the dopaminergic system.

Effects of behavioural exercise therapy on the effectiveness of multidisciplinary rehabilitation for chronic non-specific low back pain: a randomised controlled trial.

BACKGROUND: The long-term effects of behavioural medical rehabilitation (BMR), as a type of multidisciplinary rehabilitation, in the treatment of chronic non-specific low back pain (CLBP) have been shown. However, the specific effects of behavioural exercise therapy (BET) compared to standard exercise therapy (SET) within BMR are not well understood. The aim of the study was to assess the effectiveness of BMR + BET compared to BMR + SET in individuals with CLBP in a two-armed, pre-registered, multicentre, parallel, randomised controlled trial (RCT). METHODS: A total of 351 adults with CLBP in two rehabilitation centres were online randomised based on an 'urn randomisation' algorithm to either BMR + SET (n = 175) or BMR + BET (n = 176). Participants in both study groups were non-blinded and received BMR, consisting of an multidisciplinary admission, a psychosocial assessment, multidisciplinary case management, psychological treatment, health education and social counselling. The intervention group (BMR + BET) received a manualised, biopsychosocial BET within BMR. The aim of BET was to develop self-management strategies in coping with CLBP. The control group (BMR + SET) received biomedical SET within BMR with the aim to improve mainly physical fitness. Therapists in both study groups were not blinded. The BMR lasted on average 27 days, and both exercise programmes had a mean duration of 26 h. The primary outcome was functional ability at 12 months. Secondary outcomes were e.g. pain, avoidance-endurance, pain management and physical activity. The analysis was by intention-to-treat, blinded to the study group, and used a linear mixed model. RESULTS: There were no between-group differences observed in function at the end of the BMR (mean difference, 0.08; 95% CI - 2.82 to 2.99; p = 0.955), at 6 months (mean difference, - 1.80; 95% CI; - 5.57 to 1.97; p = 0.349) and at 12 months (mean difference, - 1.33; 95% CI - 5.57 to 2.92; p = 0.540). Both study groups improved in the primary outcome and most secondary outcomes at 12 months with small to medium effect sizes. CONCLUSION: BMR + BET was not more effective in improving function and other secondary outcomes in individuals with CLBP compared to BMR + SET. TRIAL REGISTRATION: Current controlled trials NCT01666639 , 16/08/2012.

Co-creating physical activity interventions: a mixed methods evaluation approach.

BACKGROUND: Co-creation strategies, such as cooperative planning, are promising as a means to ensure that physical activity interventions address real-world problems and are tailored to the target group. This has already been validated in diverse settings. However, questions targeting the transferability of cooperative planning to new settings and the key factors influencing its success or failure remain unclear. At the same time, co-creation processes are complex, and evaluation can be challenging. Following calls for detailed reporting, this paper describes the programme activities, the underlying logic, and methodological design of a study that aims to evaluate the transfer of cooperative planning to new settings and to explore the associated key determinants. METHODS: Cooperative planning was utilized as a strategy to target physical activity promotion in three real-world German settings in the nursing care and automotive mechatronics sectors. This involved researchers working alongside stakeholders from practice and policy to conjointly develop new interventions to promote physical activity in physically demanding jobs. A pragmatic approach is used to evaluate both the transferability and key determinants of this strategy. We developed a logic model for this co-creation process that describes the underlying assumptions and guides the evaluation. The evaluation outcomes of this study include planning meetings, newly developed interventions, and the determinants that are likely to affect cooperative planning. Quantitative and qualitative data will be collected using questionnaires, documents, and interviews. The quantitative data will be analysed descriptively, while the qualitative data will mainly be analysed using qualitative content analysis, split by settings. Subsequently, data triangulation will be used to integrate the quantitative and qualitative findings, which will then be compared across all three settings. DISCUSSION: The study findings will contribute to a better understanding of co-creation strategies, their transferability, and key determinants. The practical implications can include a checklist for assessing key determinants and a guideline for transferring cooperative planning into new settings to benefit more people. Ultimately, this study will help to advance co-creation strategies and may be relevant for researchers, practitioners, and policy-makers targeting physical activity promotion in various contexts. TRIAL REGISTRATION: Open Science Framework: https://osf.io/r6xnt/ (retrospectively registered).

Introducing the Practice Dive Approach: an extension of co-creation in physical activity promotion and health promotion.

Recently, there has been increasing interest in co-creation utilized for physical activity (PA) promotion and health promotion. Co-creation involves researchers and non-academic stakeholders conjointly developing and implementing interventions. In addition to the frequently reported benefits of co-creation, critical voices highlight the associated challenges (e.g. different interests that inhibit interaction). So far, research has not identified concrete solutions to these challenges and the limitations of co-creation. This article aims to introduce the Practice Dive Approach as a potential way to strengthen cooperation between researchers and non-academic stakeholders. We build on real-life experiences from a German research project, in which researchers moved into practice to familiarize themselves with the settings and end-users. After conducting a literature search on related concepts in PA/health promotion, we developed a comprehensive approach to fostering multi-sectoral cooperation. The introduced Practice Dive Approach assumes that a significant contribution to better cooperation among co-creators is the temporal immersion of researchers in their setting of interest, which has the potential to improve the success of co-creation in the PA/health promotion field. A four-level typology characterizes the intensity of researcher interactions with the setting and the non-academic stakeholders. Potential beneficial effects for both researchers and non-academic stakeholders can be hypothesized (e.g. familiarity with the setting structures and increased understanding of the end-users), while simultaneously, some challenges need to be considered. Future research should aim to validate the concept and its postulated effects.

Collaboration among researchers and non-academic stakeholders is increasingly used to promote physical activity and health. For example, people involved in such collaborations jointly develop new interventions. Potential challenges include different interests or work routines that can complicate cooperation. This article aims to introduce the Practice Dive Approach as a potential way to improve cooperation between researchers and non-academic stakeholders. We developed the approach based on observations from a German research project and a literature search on related concepts. This approach assumes that the temporal involvement of researchers in their setting of interest can strengthen research-practice cooperation and improve its success. We describe different types of a Practice Dive and the requirements for conducting Practice Dive activities. Furthermore, we present the potential effects of a Practice Dive for the researchers and the non-academic stakeholders, such as increased familiarity between both groups. However, some challenges need to be considered when applying the Practice Dive Approach. Future research should test this approach and its potential effects.

Coproduction to improve preventive health services-experiences from Germany.

Due to the beneficial impact of regular physical activity (PA) on non-communicable diseases, the number of countries integrating exercise referral schemes (ERSs) into their healthcare systems is growing. Owing to the limitations of existing PA promotion concepts in Germany's healthcare system, efforts are currently being made towards developing a nationwide referral pathway. A research group at the Friedrich-Alexander-University Erlangen-Nürnberg is coordinating these efforts within a project funded by the Federal Ministry of Health. The aim is to develop, implement and evaluate a regional-level ERS that has the potential to be scaled up across Germany in the event of its demonstrated effectiveness. The project is based on an adapted Cooperative Planning approach requiring interaction between the academic sector and different actors of the healthcare sector. The present commentary reflects on challenges faced in the early stages of the co-production process. Besides the development of an adequate co-production methodology, it critically discusses stakeholder participation, knowledge gaps and actors' willingness to take responsibility. In addition, although patients are represented by dedicated organizations, their perspective cannot be adequately captured using a co-production approach. Despite the joint development of an ERS, there remain important questions regarding the appropriateness of the co-production approach in a healthcare setting.

Regular physical activity (PA) reduces one's risk of developing various diseases and also plays a favourable role in managing symptoms and preventing further complications. Nationally and internationally, there exist different concepts on how to increase PA in the population at large. The Friedrich-Alexander-University Erlangen-Nürnberg is currently working on a project that focuses on promoting PA in primary care. This project involves collaboration among various actors in the German healthcare system, such as healthcare insurances, representatives of physicians, patients and exercise specialists, who represent different interests and are experts in their fields of knowledge. During this process, various barriers have come to light, which yield important lessons for further studies. For example, there are differences in actors' levels of knowledge of the healthcare system and their willingness to take responsibility and initiative in the collaborative process. This article should give an impression of the joint development of exercise referral schemes, show the strengths and weaknesses and encourage exchanges of similar experiences of co-production processes.

Co-producing an action-oriented framework for community-based Physical Activity Promotion in Germany.

German National Recommendations for Physical Activity (PA) and PA Promotion recommend community-based approaches to promote PA at the local level with a focus on health equity. In addition, the German Federal Prevention Act addresses health equity and strengthens setting-based health promotion in communities. However, the implementation of both in the local context remains a challenge. This article describes Phase 1 of the KOMBINE project that aims to co-produce an action-oriented framework for community-based PA promotion focusing on structural change and health equity. (i) In a series of workshops, key stakeholders and researchers discussed facilitators, barriers and needs of community-based PA promotion focusing on health equity. (ii) The research team used an inductive approach to cluster all findings and to identify key components and then (iii) compared the key components with updated literature. (iv) Key components were discussed and incorporated into a gradually co-produced framework by the participants. The first result of the co-production process was a catalog of nine key components regarding PA-related health promotion in German communities. The comparison of key components with scientific evidence showed a high overlap. Finally, a six-phase action-oriented framework including key components for community-based PA promotion was co-produced. The six-phase action-oriented framework integrates practice-based and scientific evidence on PA-related health promotion and health equity. It represents a shared vision for the implementation of National Recommendations for PA and PA Promotion in Germany. The extent to which structural changes and health equity can be achieved is currently being investigated in pilot-studies.

This paper describes how the participants in the KOMBINE project were involved in an innovative approach to transfer the German National Recommendations for Physical Activity (PA) and PA Promotion into the local practice of communities. Scientists, politicians and community actors (e.g. mayors, heads of sports departments) discussed their knowledge and experiences of facilitators, barriers and needs to promote PA in communities, specifically for people in difficult life situations (e.g. individuals with social disadvantages). Based on the results, they jointly developed key components and an action-oriented framework to implement the National Recommendations for PA and PA Promotion in German communities.

Towards a better understanding of physical activity in people with COPD: predicting physical activity after pulmonary rehabilitation using an integrative competence model.

The integrative Physical Activity-related Health Competence (PAHCO) model specifies competences (movement competence, control competence, and self-regulation competence) that enable people to lead a physically active lifestyle. This longitudinal study analyses the predictive quality of a multidimensional PAHCO assessment for levels of physical activity (PA) and their relevance for quality of life in COPD patients after pulmonary rehabilitation. At the end of an inpatient pulmonary rehabilitation (T2), 350 COPD patients participating in the Stay Active after Rehabilitation (STAR) study underwent assessments, including a six-factor measurement of PAHCO. PA (triaxial accelerometry) and quality of life (Saint George's Respiratory Questionnaire) were recorded 6 weeks (T3) and 6 months (T4) after rehabilitation. Structural equation modelling (SEM) was used to regress the PAHCO assessment on PA, which should, in turn, influence quality of life. In univariable analysis, five and six factors of the PAHCO model were related to PA and quality of life, respectively. Multivariate modelling showed that the predictive analyses for the PA level were dominated by the 6-minute walking test representing movement competence (0.562 ≤ |ß| ≤ 0.599). Affect regulation as an indicator of control competence co-predicted quality of life at T3 and levels of PA at T4. The PA level was, in turn, significantly associated with patients' quality of life (0.306 ≤ |ß| ≤ 0.388). The integrative PAHCO model may be used as a theoretical framework for predicting PA in COPD patients following pulmonary rehabilitation. The results improve our understanding of PA behaviour in COPD patients and bear implications for person-oriented PA promotion.

[Cooperative planning of measures to promote physical activity : New paths for expanding capabilities-results from the Capital4Health research consortium]. / Kooperative Planung von Maßnahmen zur Bewegungsförderung : Neue Wege zur Erweiterung von Handlungsmöglichkeiten ­ Ergebnisse aus dem Forschungsverbund Capital4Health.

BACKGROUND: Despite various national and international political initiatives for promoting physical activity at the population level, the development of effective interventions for physical activity promotion remains a challenge. In this context, there is a growing interest in participatory approaches that actively involve central setting actors in the development of specific measures. AIM OF THE ARTICLE: This article reports on the experience made by the Capital4Health research consortium while using a participatory approach called "cooperative planning" to increase capabilities for physical activity across different age groups. RESULTS: Capital4Health employed the cooperative planning approach in the childcare, school, vocational training (car mechatronics and nursing), and community setting (with a focus on men 50+). While the central elements of the approach were implemented in all settings, planning processes varied significantly with respect to the spectrum of involved actors, the number of participants and sessions, the specific measures developed, the evaluation methods, and the effects achieved at an individual and systems level. CONCLUSION: From the perspective of the Capital4Health principal investigators, the preliminary empirical results from the different settings allow for the overall conclusion that the cooperative planning approach can work and generate health promotion impact in very different settings. However, it must (and can) be adapted to the respective setting, especially in relation to involving population groups. Actors' readiness for change is crucial, as physical activity does not always have top priority in settings. In this context, key individuals can make a decisive contribution to a project's success.

[Evidence-based primary prevention and health promotion: methods and procedures in 5 research consortia]. / Evidenzbasierung in Primärprävention und Gesundheitsförderung: Methoden und Vorgehensweisen in 5 Forschungsverbünden.

Between 2014 and 2022, the 5 German research networks AEQUIPA, CAPITAL4HEALTH, HLCA, PartKommPlus, and SMARTACT are investigating topics of primary prevention and health promotion with the aim of further deepening the evidence base in these areas. The work of the 5 research networks for primary prevention and health promotion is presented, analysed, and discussed from an internal perspective. A model of evidence-based public health serves as a structuring framework.The 5 research networks use a variety of access routes for the generation of evidence with regard to the participation of nonacademic, civil society actors and users. There is a wide range of study designs - from randomised controlled trials and systematic reviews to diverse qualitative designs. The use of models and theories supports the evidence base. Beyond evidence generation, all research networks focus on at least exemplary implementation of new evidence.Due to the diversity of methods, a diversified evidence-based approach can be realised, taking into account network-specific aspects. Structural circumstances limit the further systematic strengthening of the evidence base. In particular, the involvement of nonacademic, civil society actors for the work with hard-to-reach target groups often cannot be financed or is considered too time consuming under the given circumstances. The COVID-19 pandemic highlights the importance of a flexible spectrum of methods, employing both digital and analogue methods in a meaningful way.

Moving exercise research in multiple sclerosis forward (the MoXFo initiative): Developing consensus statements for research.

Exercise as a subset of physical activity is a cornerstone in the management of multiple sclerosis (MS) based on its pleotropic effects. There is an exponential increase in the quantity of research on exercise in MS, yet a number of barriers associated with study content and quality hamper rapid progress in the field. To address these barriers and accelerate discovery, a new international partnership of MS-related experts in exercise has emerged with the goal of advancing the research agenda. As a first step, the expert panel met in May 2018 and identified the most urgent areas for moving the field forward, and discussed the framework for such a process. This led to identification of five themes, namely "Definitions and terminology," "Study methodology," "Reporting and outcomes," "Adherence to exercise," and "Mechanisms of action." Based on the identified themes, five expert groups have been formed, that will further (a) outline the challenges per theme and (b) provide recommendations for moving forward. We aim to involve and collaborate with people with MS/MS organizations (e.g. Multiple Sclerosis International Federation (MSIF) and European Multiple Sclerosis Platform (EMSP)) in all of these five themes. The generation of this thematic framework with multi-expert perspectives can bolster the quality and scope of exercise studies in MS that may ultimately improve the daily lives of people with MS.