A life span perspective on competencies for a healthy, physically active lifestyle: Findings of a data pooling initiative with over 7000 individuals.

Individuals are recommended to lead active lifestyles throughout the life course. The model of physical activity-related health competence (PAHCO) adopts a competence approach by integrating physical, cognitive, and motivational determinants for health-enhancing PA (movement competence, control competence, self-regulation competence). Drawing on a comprehensive dataset pooling, the goal of the present study was to model the idiosyncratic courses of 10 PAHCO indicators over the life span. We identified studies that empirically operationalized PAHCO, combining data of 7134 individuals (age range: 15-97 years; 61% female) from 18 different populations (prevention and rehabilitation sectors). We applied a stepwise multilevel analysis approach with disjunct sub-samples (n = 48) to examine linear and quadratic associations between age and PAHCO. Indicators of movement competence (i.e., manageability of endurance, strength, and balance demands; task-specific self-efficacy) congruently showed negative associations with age (0.054 ≤  R marg 2 ${R}_{\text{marg}}^{2}$  ≤ 0.211). However, parameters of control competence remained stable across the life span (-0.066 ≤ ß ≤ 0.028). The three indicators of self-regulation competence revealed an inconsistent relationship with age, though uncovering positive associations for self-control (ß = 0.106) and emotional attitude toward PA (ß = 0.088). The associations of some indicators varied significantly across sub-samples. The results suggest differential analyses for associations between PAHCO and age. While the physically determined PAHCO indicators (movement competence) probably decline across the life span, the ability to ensure regularity of PA (self-regulation competence) or align PAs with an individual's health (control competence) appear to remain constant or improve with increasing age. The findings reinforce a de-stigmatizing approach for PA promotion practices with considerable space for aligning activities with health also in the elderly.

Coproducing a physical activity referral scheme in Germany: a qualitative analysis of stakeholder experiences.

OBJECTIVES: This study evaluated stakeholders' experiences of participating in a coproduction process to develop a physical activity referral scheme (PARS) in the German healthcare system. The focus was on examining facilitators and challenges, along with gathering insights on potential modifications to the joint development process, all from the viewpoint of stakeholders. DESIGN: This qualitative study employed one-to-one semi-structured interviews, and the findings were analysed using summarising qualitative content analysis. SETTING: The study focused on the German healthcare system. PARTICIPANTS: Seven stakeholders from the coproduction process were purposefully selected for interviews using maximum variation sampling. The interviewees represented different sectors (physician associations, physical activity professionals' associations, health insurance companies and patient organisations), various positions within their organisations, and different levels of attendance during the coproduction process. RESULTS: In almost all interviews, the following factors were highlighted as facilitators of the development process: coproduction approach, process of coproduction, multi-sector stakeholder group, possibility of active participation, coordinating role of researchers, communication, atmosphere and interaction. In contrast, differences in roles and hierarchy, merging of different perspectives, clarification of intervention costs, and competition and conflicting interests were pointed out as challenges. Only a few suggestions regarding adaptations in terms of group composition and cooperation among stakeholders were mentioned. CONCLUSIONS: Stakeholder experiences with the joint development process were predominantly positive, indicating that coproduction is a beneficial approach for the development of PARS intended for integration into healthcare systems. The effective management of power differences among stakeholders is intricately tied to the coproduction method; therefore, it should be selected carefully. The research team plays a pivotal role in coordinating and negotiating the process, and the team should be equipped with a diverse set of skills and knowledge, particularly to understand the intricacies of the healthcare system where the PARS is intended for implementation. TRIAL REGISTRATION NUMBER: NCT04947787.

Efficacy of Physical Activity Promoting Interventions in Physical Therapy and Exercise Therapy for Persons With Noncommunicable Diseases: An Overview of Systematic Reviews.

OBJECTIVE: The objective of this study was to synthesize the evidence from systematic reviews on the efficacy of physical therapy and exercise therapy, including interventional elements explicitly aiming at physical activity promotion (PAP) in patients with noncommunicable diseases (NCDs). METHODS: PubMed, Scopus, PsycINFO, and Cochrane Database of Systematic Reviews were searched from inception to February 28, 2023. Two independent reviewers screened the literature to identify systematic reviews that evaluated the effects of physical therapy and exercise therapy, including PAP interventions. Patient-reported and device-based measures of physical activity (PA) outcomes were included. Qualitative and quantitative data from systematic reviews were extracted by 2 independent reviewers. Assessment of the methodological quality of the included systematic reviews was performed using A Measurement Tool to Assess Systematic Reviews (AMSTAR 2). We assessed primary study overlap by calculating the corrected covered area and conducted the evidence synthesis in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: Fourteen systematic reviews were included in the present overview, including patients with a variety of NCDs. Most included systematic reviews had critically low (n = 5) to low (n = 7) methodological quality. Most meta-analyses (67%; 8/12) provided evidence supporting the short- and long-term efficacy of PAP interventions, but not all pooled estimates were clinically relevant. Only three of the systematic reviews with meta-analysis included an assessment of the certainty of the evidence. The evidence from systematic reviews without meta-analysis was inconclusive. CONCLUSIONS: The results of the present overview suggest that PAP interventions in physical therapy or exercise therapy may be effective in improving PA for patients with NCDs in the short and long term. The results should be interpreted with caution due to the limited certainty of evidence and critically low-to-low methodological quality of the included systematic reviews. Both high-quality primary studies and systematic reviews are required to confirm these results. IMPACT: There is limited evidence that PAP interventions in physical therapy and exercise therapy may be effective in improving PA for patients with NCDs.

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.

Developing a policy brief on physical activity promotion for children and adolescents.

Introduction: While there are several approaches to collect basic information on physical activity (PA) promotion policies, some governments require more in-depth overviews on the situation in their country. In Germany, the Federal Ministry of Health expressed its interest in collecting detailed data on target group specific PA promotion, as relevant competences are distributed across a wide range of political levels and sectors. This study describes the development of a policy brief on physical activity promotion for children and adolescents in Germany. In particular, it addresses two major gaps in the current literature by systematically assessing good practice examples and "routine practices," i.e., PA promotion activities already taking place on large scale and regular basis. Materials and methods: Based on relevant national and international guidelines, the TARGET:PA tool was co-produced by researchers and ministry officials. It includes (1) PA recommendations, (2) national prevalence rates, (3) recommendations for PA promotion, and data on national (4) routine practices, (5) good practice projects and (6) policies. Data were collected for children and adolescents in Germany using desk research, semi-structured interviews and secondary data analysis. Results: A policy brief and scientific background document were developed. Results showed that 46% of the 4-5-year-olds fulfil WHO recommendations but only 15% of the 11-17-year-olds, and that girls are less active than boys. Currently, in Germany no valid data are available on the PA behaviour of children under the age of three. An overview of routine practices for PA promotion for children and adolescents was compiled, and experts were asked to critically assess their effectiveness, reach and durability. Overall, 339 target group specific projects for PA promotion were found, with 22 classified as examples of good practice. National PA policies for children and adolescents were identified across different sectors and settings. Conclusion: The study provides a comprehensive overview of the current status of PA promotion for children and adolescents in Germany. The co-production of the policy brief was a strength of the study, as it allowed researchers to take the needs of ministry officials into account, and as it supported the immediate uptake of results in the policymaking process. Future studies should test the applicability of the TARGET:PA tool to different target groups and countries.

Physical Activity and Risk of Major Diabetes-Related Complications in Individuals With Diabetes: A Systematic Review and Meta-Analysis of Observational Studies.

BACKGROUND: Physical activity is a cornerstone in diabetes management; however, evidence synthesis on the association between physical activity and long-term diabetes-related complications is scarce. PURPOSE: To summarize and evaluate findings on physical activity and diabetes-related complications, we conducted a systematic review and meta-analysis. DATA SOURCES: We searched PubMed, Web of Science, and the Cochrane Library for articles published up to 6 July 2021. STUDY SELECTION: We included prospective studies investigating the association between physical activity and incidence of and mortality from diabetes-related complications, i.e., cardiovascular disease (CVD), coronary heart disease, cerebrovascular events, heart failure, major adverse cardiovascular events, and microvascular complications such as retinopathy and nephropathy, in individuals with diabetes. DATA EXTRACTION: Study characteristics and risk ratios with 95% CIs were extracted. Random-effects meta-analyses were performed, and the certainty of evidence and risk of bias were evaluated with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tools. DATA SYNTHESIS: Overall, 31 studies were included. There was moderate certainty of evidence that high versus low levels of physical activity were inversely associated with CVD incidence, CVD mortality (summary risk ratio 0.84 [95% CI 0.77, 0.92], n = 7, and 0.62 [0.55, 0.69], n = 11), and microvascular complications (0.76 [0.67, 0.86], n = 8). Dose-response meta-analyses showed that physical activity was associated with lower risk of diabetes-related complications even at lower levels. For other outcomes, similar associations were observed but certainty of evidence was low or very low. LIMITATIONS: Limitations include residual confounding and misclassification of exposure. CONCLUSIONS: Physical activity, even below recommended amounts, was associated with reduced incidence of diabetes-related complications.

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.

[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.

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.

Impact of the First Wave of COVID-19 on Physical Activity Promotion in the European Union: Results From a Policymaker Survey.

BACKGROUND: The COVID-19 pandemic is a major challenge for societies and governments around the world that severely affects all aspects of health promotion. This study assesses the potential influence of the first wave of the pandemic on national physical activity promotion policy in the European Union (EU). METHODS: Data were collected using an online survey among members of the EU Physical Activity Focal Point Network, which consists of government officials from all EU member states. RESULTS: The COVID-19 pandemic has significantly affected physical activity promotion across the EU. In particular, experts indicated that it has negatively impacted opportunities for physical activity in their countries. There have, however, been positive effects of the crisis on public awareness of physical activity. While almost all countries were able to issue physical activity recommendations during quarantine, opinions varied regarding the overall impact of the pandemic on governmental capacities for physical activity promotion and policy. CONCLUSIONS: This study shows that the COVID-19 crisis has had both negative and positive effects on physical activity promotion in the EU. The positive experiences reported by some members of the Focal Point Network may assist other countries in identifying potential policy windows and strategies for the ongoing pandemic.

Long-Term Benefits of Adding a Pedometer to Pulmonary Rehabilitation for COPD: The Randomized Controlled STAR Trial.

Purpose: This Stay Active after Rehabilitation (STAR) study examined the effects of a pedometer-based behavioral intervention for individuals with COPD during three weeks of inpatient pulmonary rehabilitation (PR) on patients' physical activity levels six weeks and six months after PR, including steps (primary outcome), moderate-intensity physical activity, and sedentary time as well as patient quality of life, symptoms, and other psychological and clinical variables. Patients and Methods: Rehabilitation patients with COPD wore a triaxial accelerometer (ActiGraph wGT3X) for seven days two weeks before (T0) as well as six weeks (T3) and six months (T4) after PR. In addition to the three-week inpatient PR (control group, CG), the randomly allocated intervention group (IG) received a brief pedometer-based behavioral intervention with the application of the following behavior-change techniques: performing the behavior, individual goal-setting, self-monitoring, and feedback. The effects were analyzed using analysis of covariance with an intention-to-treat approach. Results: A total of 327 patients (69% male, age: 58 years, FEV1 (%): 53.5, six-minute walk distance: 447.8 m) were randomly allocated to either the IG (n = 167) or CG (n = 160). Although both groups increased their daily steps after PR (IG: MT3-T0 = 1152, CG: MT3-T0 = 745; IG: MT4-T0 = 795, CG: MT4-T0 = 300), the slightly higher increases in daily steps in the IG compared to the CG at T3 (Δ388 steps, d = 0.16) and T4 (Δ458 steps, d = 0.15) were not statistically significant (p > 0.05 for all). Patients in both groups showed moderate to high pre-post-changes in terms of secondary outcomes, but no advantage favoring the IG was found. Conclusion: The results show that adding a pedometer-based behavioral intervention to standard German three-week inpatient PR for COPD patients did not result in more physical activity in terms of steps and moderate-intensity physical activity or less sedentary time. However, both groups (IG and CG) showed remarkably enhanced physical activity levels six weeks and six months after PR, as well as improvements in other secondary outcomes (eg, quality of life).

Physical activity referral scheme components: a study protocol for systematic review and meta-regression.

INTRODUCTION: In its attempt to establish effective physical activity promotion methods, research on physical activity referral schemes (PARS) is attracting significant attention. Sometimes known as physical activity on prescription schemes, PARS involve a well-defined procedure whereby a primary healthcare professional introduces a participant to the topic of physical activity and employs prescription or referral forms to connect the participant to physical activity opportunities, such as local fitness offers. The planned systematic review will focus on these referral routes and scheme components and how they are integrated into various PARS models worldwide. We seek to identify the evidence-based core components that play the most important roles in the effectiveness of PARS. METHODS AND ANALYSIS: The development and reporting of the protocol follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We plan to conduct a systematic main literature search on PubMed, Scopus, Web of Science, CINAHL, HTA, SpringerLink and other databases. We will include studies that report outcomes on physical activity, PARS uptake and adherence rates or descriptive information about PARS models. We intend for all review stages, citation screening, data extraction and risk of bias assessment to be conducted by at least two independent reviewers. As a broad spectrum of study designs, including randomised and non-randomised studies of interventions and mixed methods, will be eligible, we will use three separate tools to assess the risk of bias in individual studies. The data will be primarily synthesised narratively, following Intervention Component Analysis. If the data allow, we will perform a random-effects meta-analysis and meta-regression to investigate the impact of specific PARS components on effect sizes. ETHICS AND DISSEMINATION: This systematic review does not require formal ethics approval. The results will be submitted to a peer-reviewed journal and international conferences to reach the scientific community. PROSPERO REGISTRATION NUMBER: CRD42021233229.

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.

Development, implementation, evaluation and scaling-up of physical activity referral schemes in Germany: protocol for a study using a co-production approach.

INTRODUCTION: Physical activity referral schemes (PARSs) are recommended to promote physical activity (PA) among adults at risk of developing or with established non-communicable diseases (NCDs). In Germany, this kind of referral schemes has not yet been implemented systematically and nationwide. In this study protocol, we present the methodological design of a co-production research study aimed at establishing a PARS for adults with NCDs in German primary healthcare. METHODS AND ANALYSIS: We will employ a co-production approach consistently throughout the four project phases: (1) development of the PARS; (2) preparation period; (3) implementation and evaluation; (4) development of a strategic plan for scaling up the PARS to the national level as part of standard care. The first phase will additionally include a status quo analysis of the existing physical activity pathways nationwide as well as an overview of international PARS models. A pragmatic trial design will be used for evaluating the developed PARS. The co-production approach will involve relevant actors in the German healthcare system, namely, healthcare service providers (eg, physicians, exercise professionals), health insurance providers, exercise providers, patients' representatives, experts in the development and implementation of educational concepts, and scientists from the fields of sports science and public health. ETHICS AND DISSEMINATION: The project has been reviewed and approved by the ethics committee of the Friedrich-Alexander-University Erlangen-Nürnberg (ethics approval number: 331_20 B). Through cooperation agreements, the stakeholders involved gave their consent to participate and were informed about the study in detail. The results of this study will be disseminated by international conference presentations and peer-reviewed publications, and if possible, a manual for the use of the PARS will be provided.

Physical inactivity in healthy, obese, and diabetic adults in Germany: An analysis of related socio-demographic variables.

BACKGROUND: Adults with diabetes or obesity are more likely to be physically inactive than healthy adults. Physical activity is essential in the management of both diseases, necessitating targeted interventions in these groups. This study analysed physical inactivity (defined as not taking part in leisure-time physical activity) in over 100,000 adults in Germany considering their body mass index and the presence of diabetes. Furthermore, the relationship between specific socio-demographic factors with physical inactivity was investigated, particularly focussing diabetic and obese people, to refine the identification of risk-groups for targeted interventions on physical activity promotion. METHODS: Data from 13 population-based health surveys conducted in Germany from 1997 to 2018 were used. The relevant variables extracted from these datasets were merged and employed in the analyses. We included data from 129,886 individuals in the BMI analyses and 58,311 individuals in the diabetes analyses. Logistic regression analyses were performed to identify the importance of six socio-demographic variables (age, sex/gender, education, income, employment, and migration) for the risk of physical inactivity. RESULTS: Obese and diabetic people reported a higher prevalence of physical inactivity than those who were not affected. Logistic regression analyses revealed advanced age, low education level, and low household income as risk factors for physical inactivity in all groups. A two-sided migration background and unemployment also indicated a higher probability of physical inactivity. CONCLUSION: Similar socio-demographic barriers appear to be important determinants of physical inactivity, regardless of BMI status or the presence of diabetes. However, physical activity promoting interventions in obese and diabetic adults should consider the specific disease-related characteristics of these groups. A special need for target group specific physical activity programmes in adults from ethnic minorities or of advanced age was further identified.

Exercise Therapy Teamwork in German Rehabilitation Settings: Results of a National Survey Using Mixed Methods Design.

A key prerequisite for implementing biopsychosocial exercise therapy concepts as parts of multimodal rehabilitation programs is interprofessional teamwork. Based on a nationwide survey of exercise therapy using a mixed methods design, it is of interest to determine to what extent there are links between team-related processes (e.g., interprofessional exchange) and structural features of the exercise therapy departments (e.g., department size) and the individual rating of interprofessional teamwork. The first part of the study involved a questionnaire-based survey, where exercise therapy heads of 1146 rehabilitation facilities were contacted. In the second part of the study, 58 exercise therapy heads held discussions in six focus groups. The results from both parts showed that interprofessional teamwork was rated positively overall. Team meetings were seen as the central platform for exchange. However, particularly in larger facilities, the hierarchical position of medical management and lacking resources were negatively associated with interprofessional exchange. The results affirm empirically that a more binding provision of adequate structural and organizational conditions, such as sufficient time slots for liaising on content, are essential for effective teamwork. This would facilitate and improve the promotion of physical activity in multimodal rehabilitation programs.

Competencies for a Healthy Physically Active Lifestyle-Validation of an Integrative Model.

Purpose: The model of physical activity-related health competence (PAHCO) provides an integrative and interdisciplinary view on competencies that are necessary when people want to lead a healthy, physically active lifestyle. Given the need to accumulate potential further evidence on the validity of this model through the development of an assessment tool, the goal of the present study was to extend first measurement models on PAHCO. Method: In Study 1, a measurement model with five predictors on PAHCO was tested with 341 COPD patients undergoing inpatient rehabilitation. In Study 2, data from 745 apprentices were used to create an extended eight-factor measurement model. We undertook reliability analysis, confirmatory factor analysis (CFA), and structural equation modeling (SEM) to assess the validity of the models. Results: The analyses showed good results for the reliability and discriminant validity of the factors. Accordingly, the CFA demonstrated satisfactory overall fits for the five-factor as well as for the extended eight-factor measurement model. The associations with physical activity and physical health parameters indicated criterion validity for seven of the eight PAHCO factors. The explained variance of the multivariate models lay between 9.8% and 10.4% in Study 1 and between 9.5% and 21.3% in Study 2. Conclusion: In the present study, it was possible to extract a well-fitting, eight-factor measurement model and accumulate further evidence on the validity of the PAHCO model. Future research should strive for a cross-validation of the measurement model and more deeply investigate the internal structure of the eight factors.

Dose-response relationship between physical activity and mortality in adults with noncommunicable diseases: a systematic review and meta-analysis of prospective observational studies.

BACKGROUND: This study aims to investigate the relationship between post-diagnosis physical activity and mortality in patients with selected noncommunicable diseases, including breast cancer, lung cancer, type 2 diabetes, ischemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), osteoarthritis, low back pain and major depressive disorder. METHODS: A systematic search was conducted of PubMed, Scopus and the Web of Science from their inception to August 2018. Additionally, the search was updated in August 2019. Eligibility criteria included prospective observational studies examining the relationship between at least three physical activity categories (e.g. low, moderate, high) and all-cause mortality as the primary outcome. RESULTS: In total, 28 studies were included in the meta-analysis: 12 for breast cancer, 6 for type 2 diabetes, 8 for ischemic heart disease and 2 for COPD. The linear meta-analysis revealed that each 10 metabolic equivalent task hours increase of physical activity per week was associated with a 22% lower mortality rate in breast cancer patients (Summary Hazard Ratio [HR], 0.78; 95% CI: 0.71, 0.86; I2: 90.1%), 12% in ischemic heart disease patients (HR, 0.88; 95% CI: 0.83, 0.93; I2: 86.5%), 30% in COPD patients (HR, 0.70; 95% CI: 0.45, 1.09; I2: 94%) and 4% in type 2 diabetes patients (HR, 0.96; 95% CI: 0.93, 0.99; I2: 71.8%). There was indication of a non-linear association with mortality risk reductions even for low levels of activity, as well as a flattening of the curve at higher levels of activity. The certainty of evidence was low for breast cancer, type 2 diabetes and ischemic heart disease but only very low for COPD. CONCLUSION: Higher levels of post-diagnosis physical activity are associated with lower mortality rates in breast cancer, type 2 diabetes, ischemic heart disease and COPD patients, with indication of a no-threshold and non-linear dose-response pattern.

German recommendations for physical activity and physical activity promotion in adults with noncommunicable diseases.

BACKGROUND: Existing physical activity guidelines predominantly focus on healthy age-stratified target groups. The objective of this study was to develop evidence-based recommendations for physical activity (PA) and PA promotion for German adults (18-65 years) with noncommunicable diseases (NCDs). METHODS: The PA recommendations were developed based on existing PA recommendations. In phase 1, systematic literature searches were conducted for current PA recommendations for seven chronic conditions (osteoarthrosis of the hip and knee, chronic obstructive pulmonary disease, stable ischemic heart disease, stroke, clinical depression, and chronic non-specific back pain). In phase 2, the PA recommendations were evaluated on the basis of 28 quality criteria, and high-quality recommendations were analysed. In phase 3, PA recommendations for seven chronic conditions were deducted and then synthesised to generate generic German PA recommendations for adults with NCDs. In relation to the recommendations for PA promotion, a systematic literature review was conducted on papers that reviewed the efficacy/effectiveness of interventions for PA promotion in adults with NCDs. RESULTS: The German recommendations for physical activity state that adults with NCDs should, over the course of a week, do at least 150 min of moderate-intensity aerobic PA, or 75 min of vigorous-intensity aerobic PA, or a combination of both. Furthermore, muscle-strengthening activities should be performed at least twice a week. The promotion of PA among adults with NCDs should be theory-based, specifically target PA behaviour, and be tailored to the respective target group. In this context, and as an intervention method, exercise referral schemes are one of the more promising methods of promoting PA in adults with NCDs. CONCLUSION: The development of evidence-based recommendations for PA and PA promotion is an important step in terms of the initiation and implementation of actions for PA-related health promotion in Germany. The German recommendations for PA and PA promotion inform adults affected by NCDs and health professionals on how much PA would be optimal for adults with NCDs. Additionally, the recommendations provide professionals entrusted in PA promotion the best strategies and interventions to raise low PA levels in adults with NCDs. The formulation of specific PA recommendations for adults with NCDs and their combination with recommendations on PA promotion is a unique characteristic of the German recommendations.