Evaluation of an intervention to promote walking during the commute to work: a cluster randomised controlled trial.

BACKGROUND: Opportunities for working adults to accumulate recommended physical activity levels (at least 150 min of moderate intensity physical activity in bouts of at least 10 min throughout the week) may include the commute to work. Systematic reviews of interventions to increase active transport suggest studies have tended to be of poor quality, relying on self-report and lacking robust statistical analyses. METHODS: We conducted a multi-centre parallel-arm cluster randomised controlled trial, in workplaces in south-west England and south Wales, to assess the effectiveness of a behavioural intervention to increase walking during the commute. Workplace-based Walk to Work promoters were trained to implement a 10-week intervention incorporating key behavioural change techniques: providing information; encouraging intention formation; identifying barriers and solutions; goal setting; self-monitoring; providing general encouragement; identifying social support; reviewing goals, and; relapse prevention. Physical activity outcomes were objectively measured using accelerometers and GPS receivers at baseline and 12-month follow-up. The primary outcome was daily minutes of moderate to vigorous physical activity (MVPA). Secondary outcomes included overall levels of physical activity and modal shift (from private car to walking). Cost-consequences analysis included employer, employee and health service costs and outcomes. RESULTS: Six hundred fifty-four participants were recruited across 87 workplaces: 10 micro (5-9 employees); 35 small (10-49); 22 medium (50-250); 20 large (250+). The majority of participants lived more than two kilometres from their place of work (89%) and travelled to work by car (65%). At 12-month follow-up, 84 workplaces (41 intervention, 43 control) and 477 employees (73% of those originally recruited) took part in data collection activities. There was no evidence of an intervention effect on MVPA or overall physical activity at 12-month follow-up. The intervention cost on average £181.97 per workplace and £24.19 per participating employee. CONCLUSIONS: The intervention, focusing primarily on individual behaviour change, was insufficient to change travel behaviour. Our findings contribute to the argument that attention should be directed towards a whole systems approach, focusing on interactions between the correlates of travel behaviour. TRIAL REGISTRATION: ISRCTN15009100 . Prospectively registered. (Date assigned: 10/12/2014).

Employers' views of promoting walking to work: a qualitative study.

BACKGROUND: Physical inactivity increases the risk of many chronic diseases including coronary heart disease, type 2 diabetes, obesity and some cancers. It is currently recommended that adults should undertake at least 150 minutes of moderate physical activity in bouts of 10 minutes or more throughout the week. One way for adults in employment to incorporate exercise into their daily routine is to walk during the commute to and from work. Schemes to promote active travel require the support of employers and managers but there is a lack of research focusing on their views and experiences of promoting walk to work schemes. METHODS: This study presents the findings from in-depth, digitally recorded interviews with 29 employers from a range of small, medium and large workplaces who participated in a feasibility study to develop and test an employer-led scheme to promote walking to work. All recordings were fully transcribed. The Framework approach for data management was used to aid qualitative analysis. Interview transcripts were read and reread, and textual data were placed in charts focusing on facilitators, barriers, and possibilities for employers to promote walking to work. RESULTS: A range of perspectives were identified, from active support through uncertainty and cynicism to resistance. The majority of employers who took part in the study were unclear about how to give practical support for employees who walk to work, but appeared more confident about ideas to promote cycling. Some employers were concerned about how their attempts to promote walking might be perceived by employees. Furthermore, the main business of their organisation took priority over other activities. CONCLUSIONS: It is clear that employers need more evidence of the effectiveness of walk to work schemes, and the benefits to employers of committing resources to them. Furthermore, employers need support in creating an authentic, health promoting ethos within the workplace to enhance positive relationships and reduce tensions that may arise when promoting active travel initiatives.

Study protocol: the effectiveness and cost effectiveness of an employer-led intervention to increase walking during the daily commute: the Travel to Work randomised controlled trial.

BACKGROUND: Physical inactivity increases the risk of many chronic diseases including coronary heart disease, type 2 diabetes and some cancers. It is recommended that adults should undertake at least 150 minutes of moderate intensity physical activity throughout the week but many adults do not achieve this. An opportunity for working adults to accumulate the recommended activity levels is through the daily commute. METHODS: Employees will be recruited from workplaces in south-west England and south Wales. In the intervention arm, workplace Walk-to-Work promoters will be recruited and trained. Participating employees will receive Walk-to-Work materials and support will be provided through four contacts from the promoters over 10 weeks. Workplaces in the control arm will continue with their usual practice. The intervention will be evaluated by a cluster randomized controlled trial including economic and process evaluations. The primary outcome is daily minutes of moderate to vigorous physical activity (MVPA). Secondary outcomes are: overall physical activity; sedentary time; modal shift away from private car use during the commute; and physical activity/MVPA during the commute. Accelerometers, GPS receivers and travel diaries will be used at baseline and one year follow-up. Questionnaires will be used at baseline, immediately post intervention, and one year follow-up. The process evaluation will examine the context, delivery and response to the intervention from the perspectives of employers, Walk-to-Work promoters and employees using questionnaires, descriptive statistics, fieldnotes and interviews. A cost-consequence study will include employer, employee and health service costs and outcomes. Time and consumables used in implementing the intervention will be measured. Journey time, household commuting costs and expenses will be recorded using travel diaries to estimate costs to employees. Presenteeism, absenteeism, employee wellbeing and health service use will be recorded. DISCUSSION: Compared with other forms of physical activity, walking is a popular, familiar and convenient, and the main option for increasing physical activity in sedentary populations. To our knowledge, this is the first full-scale randomised controlled trial to objectively measure (using accelerometers and GPS receivers) the effectiveness of a workplace intervention to promote walking during the commute to and from work. TRIAL REGISTRATION: ISRCTN15009100 (10 December 2014).

The contribution of walking to work to adult physical activity levels: a cross sectional study.

OBJECTIVE: To objectively examine the contribution to adult physical activity levels of walking to work. METHODS: Employees (n = 103; 36.3 ± 11.7 years) at 17 workplaces in south-west England, who lived within 2 miles (3.2 km) of their workplace, wore Actigraph accelerometers for seven days during waking hours and carried GPS receivers during the commute to and from work. Physical activity volume (accelerometer counts per minute (cpm)) and intensity (minutes of moderate to vigorous physical activity (MVPA)) were computed overall and during the walk to work. RESULTS: Total weekday physical activity was 45% higher in participants who walked to work compared to those travelling by car (524.6. ± 170.4 vs 364.6 ± 138.4 cpm) and MVPA almost 60% higher (78.1 ± 24.9 vs 49.8 ± 25.2 minutes per day). No differences were seen in weekend physical activity, and sedentary time did not differ between the groups. Combined accelerometer and GPS data showed that walking to work contributed 47.3% of total weekday MVPA. CONCLUSIONS: Walking to work was associated with overall higher levels of physical activity in young and middle-aged adults. These data provide preliminary evidence to underpin the need for interventions to increase active commuting, specifically walking, in adults.

Views and experiences of behaviour change techniques to encourage walking to work: a qualitative study.

BACKGROUND: High levels of physical inactivity are linked to several chronic diseases including coronary heart disease, type-2 diabetes, obesity, some cancers and poor mental health. Encouraging people to be more active has proven difficult. One way to incorporate physical activity into the daily routine is through the journey to and from work. Although behaviour change techniques (BCTs) are considered valuable in promoting behaviour change, there is very little in the published literature about the views and experiences of those encouraged to use them. METHODS: The Walk to Work study was a feasibility study incorporating an exploratory cluster randomised controlled trial. The 10-week intervention involved training workplace-based Walk to Work promoters (volunteers or nominated by participating employers) to encourage colleagues to increase walking during their daily commute. The intervention used nine specific BCTs: Intention formation, barrier identification, specific goal setting, instruction, general encouragement, self-monitoring of behaviour social support, review of behavioural goals and relapse prevention. Digitally recorded interviews were undertaken with 22 employees, eight of whom were Walk to Work promoters to understand their views and experiences of using these techniques. The Framework method of data management and constant comparison were used to analyse the data and identify key themes. RESULTS: For each individual BCT, there appeared to be people who found it useful in helping them to increase walking to work and others who did not. Following training, the Walk to Work promoters varied in the extent to which they were able to fulfil their role: additional support and encouragement during the 10-week intervention may be required for the promoters to maintain motivation. Wider contextual (economic climate, unprecedented wet weather) and organisational (workload, car parking facilities) issues were identified that influenced the delivery of, and response to, the intervention. CONCLUSIONS: Walk to work interventions employing BCTs should include sufficient techniques to enable participants to choose a 'package' to suit their needs. Additional support at organisational level should also be encouraged, and consideration given to wider contextual factors that impinge on the delivery of, and response to, the intervention. TRIAL REGISTRATION: ISRCTN72882329.

Complex consultations in primary care: a tool for assessing the range of health problems and issues addressed in general practice consultations.

BACKGROUND: There is an increasing recognition that many consultations in general practice involve several problems covering multiple disease domains. However there is a paucity of reliable tools and techniques to understand and quantify this phenomenon. The objective was to develop a tool that can be used to measure the number and type of problems discussed in primary care consultations. METHODS: Thirteen consultations between general practitioners and patients were initially videoed and reviewed to identify the problems and issues discussed. An iterative process involving a panel of clinicians and researchers and repeated cycles of testing and development was used to develop a measurement proforma and coding manual for assessment of video recorded consultations. The inter-rater reliability of this tool was assessed in 60 consultations. RESULTS: The problems requiring action were usually readily identified. However the different dimensions of the problem and how they were addressed required the identification and definition of 'issues'. A coding proforma was developed that allowed quantification of the numbers and types of health problems and issues discussed. Ten categories of issues were identified and defined. At the consultation level, inter-rater agreements for the number of problems discussed (within ± 1), types of problems and issues were 98.3%, 96.5% and 90% respectively. The tool has subsequently been used to analyse 229 consultations. CONCLUSION: The iterative approach to development of the tool reflected the complexity of doctor-patient interactions. A reliable tool has been developed that can be used to analyse the number and range of problems managed in primary care consultations.

The high-volume haemodiafiltration vs high-flux haemodialysis registry trial (H4RT): a multi-centre, unblinded, randomised, parallel-group, superiority study to compare the effectiveness and cost-effectiveness of high-volume haemodiafiltration and high-flux haemodialysis in people with kidney failure on maintenance dialysis using linkage to routine healthcare databases for outcomes.

BACKGROUND: More than a third of the 65,000 people living with kidney failure in the UK attend a dialysis unit 2-5 times a week to have their blood cleaned for 3-5 h. In haemodialysis (HD), toxins are removed by diffusion, which can be enhanced using a high-flux dialyser. This can be augmented with convection, as occurs in haemodiafiltration (HDF), and improved outcomes have been reported in people who are able to achieve high volumes of convection. This study compares the clinical- and cost-effectiveness of high-volume HDF compared with high-flux HD in the treatment of kidney failure. METHODS: This is a UK-based, multi-centre, non-blinded randomised controlled trial. Adult patients already receiving HD or HDF will be randomised 1:1 to high-volume HDF (aiming for 21+ L of substitution fluid adjusted for body surface area) or high-flux HD. Exclusion criteria include lack of capacity to consent, life expectancy less than 3 months, on HD/HDF for less than 4 weeks, planned living kidney donor transplant or home dialysis scheduled within 3 months, prior intolerance of HDF and not suitable for high-volume HDF for other clinical reasons. The primary outcome is a composite of non-cancer mortality or hospital admission with a cardiovascular event or infection during follow-up (minimum 32 months, maximum 91 months) determined from routine data. Secondary outcomes include all-cause mortality, cardiovascular- and infection-related morbidity and mortality, health-related quality of life, cost-effectiveness and environmental impact. Baseline data will be collected by research personnel on-site. Follow-up data will be collected by linkage to routine healthcare databases - Hospital Episode Statistics, Civil Registration, Public Health England and the UK Renal Registry (UKRR) in England, and equivalent databases in Scotland and Wales, as necessary - and centrally administered patient-completed questionnaires. In addition, research personnel on-site will monitor for adverse events and collect data on adherence to the protocol (monthly during recruitment and quarterly during follow-up). DISCUSSION: This study will provide evidence of the effectiveness and cost-effectiveness of HD as compared to HDF for adults with kidney failure in-centre HD or HDF. It will inform management for this patient group in the UK and internationally. TRIAL REGISTRATION: ISRCTN10997319 . Registered on 10 October 2017.

The content of general practice consultations: cross-sectional study based on video recordings.

BACKGROUND: Demographic and policy changes appear to be increasing the complexity of consultations in general practice. AIM: To describe the number and types of problems discussed in general practice consultations, differences between problems raised by patients or doctors, and between problems discussed and recorded in medical records. DESIGN AND SETTING: Cross-sectional study based on video recordings of consultations in 22 general practices in Bristol and North Somerset. METHOD: Consultations were examined between 30 representative GPs and adults making a pre-booked day-time appointment. The main outcome measures were number and types of problems and issues discussed; who raised each problem/issue; consultation duration; whether problems were recorded and coded. RESULTS: Of 318 eligible patients, 229 (72.0%) participated. On average, 2.5 (95% CI = 2.3 to 2.6) problems were discussed in each consultation, with 41% of consultations involving at least three problems. Seventy-two per cent (165/229) of consultations included problems in multiple disease areas. Mean consultation duration was 11.9 minutes (95% CI = 11.2 to 12.6). Most problems discussed were raised by patients, but 43% (99/229) of consultations included problems raised by doctors. Consultation duration increased by 2 minutes per additional problem. Of 562 problems discussed, 81% (n = 455) were recorded in notes, but only 37% (n = 206) were Read Coded. CONCLUSION: Consultations in general practice are complex encounters, dealing with multiple problems across a wide range of disease areas in a short time. Additional problems are dealt with very briefly. GPs, like patients, bring an agenda to consultations. There is systematic bias in the types of problems coded in electronic medical records databases.