Increasing Physical Activity Levels in Children and Young people: What can AHPs do?

My latest blog post was written  for the Department of Health and Public Health England's week of action focussing on Children and Young People.  The aim of this joint initiative is help support families to give children and young people the best start in life.  

The blog post is on the Department of Health website and can be accessed by clicking on the link below;


https://vivbennett.blog.gov.uk/2014/11/21/increasing-physical-activity-levels-in-children-and-young-people-what-can-ahps-do-by-anna-lowe/

Changing Health Behaviours

There has been much talk recently about Behaviour Change.  This is, in part I think, due to the realisation that health care alone does not determine health, it influences it, but not nearly as much as we thought. These pie charts from The King's Fund show estimates of how much (or little) health care contributes to overall health.  Click here & scroll down to see the images more clearly.

The first pie chart suggests that health behaviour patterns may contribute to overall health by 40%, compared to health care at 15% (McGiniss et al 2002).  It's information like this that has brought techniques that facilitate changes in behaviour into sharp focus.

I really like this infographic from Evans Health Lab, it summarises some of the key ways in which we already encourage healthy behaviours.  It highlights the fact that it's usually clusters of behaviour that we are targeting and it advocates an individual, intuitive and tacit approach.

Earlier this year NICE published guidance on Behaviour Change,  I've mentioned in previous blog posts that I think physios are natural facilitators of behaviour change but I think that to date our approaches have been intuitive.  The NICE guidelines clearly state the importance of engaging with behaviour change strategies but this needs to be done in a way that is recognised outside of physiotherapy practice.

This week Quality Watch published their report "Allied health professional.  Can we measure quality of care?" the authors of the report acknowledge the need for AHPs in view of the ageing population and the increasing numbers of people with long-term conditions.  However, they also acknowledge that the contribution made by AHPs is often "hidden, overlooked or potentially undervalued" this is something I can relate to and it makes our services vulnerable.  We simply have to be able to demonstrate that we are effective and that our contributions count but this is no longer limited to treatment of the presenting complaint.  We have the opportunity to be recognised a key "deliverers" of public health priorities and we have the opportunity to establish ourselves as an integral part of the public health workforce.

With this in mind, rather than taking an intuitive approach to changing behaviour we may need to formalise what we do so that it is very clear to other people (managers, commissioners etc) exactly what we are doing.  I think that for this to happen we probably need to do some or all of the following;

1. Clinical staff need training in this area and need supporting in their practise.
2. Decide the scope of our remit, we can't change everything, which health behaviours are we going to target.  The four biggies are smoking, alcohol, activity and nutrition, we need a strategy and I can't help feeling that focusing on Physical Activity would be the sensible option for physiotherapists.
3. Decide which approach works best in our clinical environment, one size does not fit all, does your service lend itself to very brief interventions or to high intensity interventions?
4. Develop a consistent approach.
5. Record what we do.
6. Collate our records, at an individual level, a team level a departmental level and a national level.
7. Evaluate what we are doing.
8. Tell the world!

We need to be canny about this, we need to be able to demonstrate our activity and effectiveness in a universal language.  We can't change our practice suddenly or dramatically, there are HUGE constraints on our time & resources, but we can subtly shift the way in which we deliver behaviour change interventions to ensure that we are ticking the right boxes and getting the recognition we need and deserve.

Local Knowledge

Physios can be quite a mobile profession, it's good to move around and work in different places, we locum, we travel abroad all of which are great opportunities but they can mean that we end up working in geographical areas that we don't know anything about.  There are a number of reasons why it's good to understand your local area and your local population; it's good for your patients and it's good for your service.

The SOCIAL bit of the biopyschosocial approach doesn't get much attention in physio yet it essential to understand the wider social and economic context that a patient comes from.  Our values, experiences of pain, expectations and healthcare outcomes are all influenced by the environment in which we live.  The King's Fund provide some great information on how the broader determinants  of health (summarised in the above picture) are likely to impact on future trends in health.

Understanding this gives our assessments and interventions context, it helps us communicate effectively with patients, it allows us to make informed recommendations about local services and facilities.  For example, we might say to a patient "try and get out for a 20 minute walk every evening" when in certain areas local parks are poorly lit, covered in dog poo and dangerous at night.  Most areas have masses and masses of brilliant physical activity options and these are often a perfect "next step" after physio treatment but keeping updated on local events, groups and charities is time consuming and it's something that is often left to patients.  One local Physiotherapy Department has appointed one member of the team to collate this information and to brief the team about community events & groups at regular intervals; what a great idea!

Being aware of local health priorities can also help your services, health care services are commissioned in response to local need and understanding the health priorities in your area is an essential way of ensuring that your services match local need.  The Health Profiles created by Public Health England (PHE) provide an overview of local health priorities.  Here in Sheffield for example, statistics are significantly worse than the average for England in the areas of deprivation, smoking, educational attainment, mortality in under 75s from both cancer & CVD.

Deprivation is higher than the national average and life expectancy is lower than the national average.  Sheffield is known as a city in inequalities and there is a massive 10 year difference in life expectancy in males in the most deprived and least deprived areas of the city.  We need to show how our services are addressing these inequalities and in doing so demonstrate that this is a priority for our profession.

Another key document is the local Joint Needs Assessment Strategy, these can usually be found on your local government website.  This document provides an analysis of the current health needs of the local area, it informs the local health & wellbeing strategy and it informs commissioning activity in health and social care.  In Sheffield the JSNA builds on the information in the local health profile and a key aspiration is to bring life expectancy in line with the national average, it analysis the causes of premature death and highlights trends in areas including neurological conditions, diabetes, dementia and COPD.  It concludes that long term conditions are a leading cause of premature death and states that these must be a priority for commissioners.

We need to keep up with population health trends and understanding local health prioroties and developing links with local communities can help our services evolve to meet the needs of the local population.

The Role of the Physio in Preventing Obesity

I recently spent some time with a local weight management service, it was a great to see physios making a real difference to people’s lives. I was interested to hear that people don’t meet the referral criteria for the service unless they have a BMI of 35 + comorbidities, or a BMI of 40 without comorbidities (...show me someone with a BMI of 40 without co-morbidities!). By the time someone has a BMI of 35 (this roughly equates to a weight of 17 ½ stone for someone who is 5’ 10’’) they are in serious trouble and common sense would suggest that preventing this situation is better for the individual and more cost effective than trying to deal with it further down the line.

This made me think about the huge number of people with a BMI of 25-35, overweight and fast heading towards obesity, gradually accumulating risk factors over the years, what are we doing as physios to be proactive about this? We seem to be carving a nice role for ourselves in obesity management services but I don't know how much activity there is in pro-active, preventative action and it is concerning that someone could be considered Obese Class II but still not be eligable for referral to their local weight management service.

So what could we be doing? 

We see patients who are overweight all the time!  We could integrate discussion about weight into our standard assessment process, be it during acute stroke rehab, in fracture clinic or LBP classes . Broaching the question of weight with patients can be daunting but we are great communicators and if it’s raised in a sensitive, timely way it can create an opportunity for change and there are some useful resources available to help with this.   I'm not advocating quizzing everyone about their weight but if we were to ask people “How do you feel about your weight?” or “Is your weight something you would like to change?” then we are opening a dialogue, if the patient is happy and isn’t interested in changing their weight then we move on. As ever, a standard approach is unlikely to work, we need to take cues from patients and tailor our approach accordingly.  A recent US study suggests that care needs to be taken with language, it found that the terms that were rated as most desirable were "weight, unhealthy weight", the terms that were rated most motivating to lose weight were "unhealthy weight, overweight" and the terms that were rated as most undesirable, stigmatising and blaming were "morbidly obese, fat, obese". 

We could also integrate routine weight monitoring into physio sessions, it takes 2 minutes and it allows us to have discussions about the risks associated with weight gain and the benefits of physical activity and nutrition. It also sends a message to the patient that we consider weight management to be important.

We could signpost patients to other services, not just NHS Obesity services with limited referral criteria but also to commercial ventures aimed at maintaining a healthy weight.  There's Slimming World, Weight Watchers, gym-based weight management programmes as well as the exercise classes that we regularly recomend for patients.  My local GP practice hosts WeightWatchers sessions, should we be doing this too?

Or there could be a role for developing you own service targeting people at risk of obesity.  We have expertise in longterm conditions, behaviour change and physical activity, we often have colleagues in Dietetics, Nutrition & Psychology with whom we could collaborate, we have facilities in our departments & gyms and we have a large throughput of patients many of whom would like to change their weight.

Maybe it is time to embrace our role in preventing obesity as well as in managing it? 

The Role of the Physio in Obesity Management

Nice guidelines on the management of obesity were publishes recently and the CSP expressed disappointment that the role of the physio wasn't specifically mentioned.  Obesity is such a complex issue that it requires multilevel, multidisciplinary & multiagency approaches.  Approaches that are tailored to the individual and that involves family and carers.  Behaviour change in any situation is difficult but in this highly complex situation there are so many barriers to change that we need to pull out all the stops in terms of wrap-around interventions.  This infographic shows the complexity of the causes of obesity (if you can't see it clearly, see the Public Health England website).

 

In my experience many physios don’t feel equipped to tackle obesity, it might not have featured in their training, they might not have been on a course but I firmly believe that we are particularly well placed to lead action on obesity for a number of reasons.

1. We are used to working with complex patients, we are not phased by long lists of medication and complex comorbidities, our broad clinical experience equips us to be problem solvers and to tailor our interventions to the individual.
2. By the same token, we are not risk averse, rehab is all about graded exposure to risk and physios are great at recognising risk and balancing risk.  One thing we absolutely have to keep in mind is that, with obesity, there is risk inherent in doing nothing!  There are some great risk stratification tools available to help plan exercise interventions with complex client groups.
3. We are the exercise experts, it’s our bread and butter and there is a lot to suggest that it will become even more central to what we do.  We need to send out a clear message that we are competent and confident in this key area of physiotherapy practice.
4. Physios are awesome communicators, we spend our days connecting with people and we are lucky enough to spend sufficient time with patients to develop meaningful therapeutic relationships.
5. We have a huge amount of practical expertise in behaviour change,  we spend our days trying to get people to do stuff that they don’t really want to do, we have lots of tricks up our sleeve and we  know intuitively how to select an appropriate approach for an individual.
6. We don’t judge, we understand enough about obesity to know that it isn’t simply a decision to overeat, it is far, far more complex than this and as the infographic above shows, there are many contributory factors. You don’t often meet obese people with  good quality of life, we don't judge, we show compassion because we care!

We do have a unique skill mix that lends itself to working to manage obesity, I can see that it is a natural fit for our profession and I hope that we will continue to establish ourselves as leaders in this area.  I do however think that we have a role that is at least as important in the prevention of obesity and I don't see much activity in this area.  More in the next blog post!

Follow me on twitter: @annalowephysio

 

 

What is public health anyway?

Physiotherapy IS Public Health

I’m a physio and  several years ago I went on a public health (PH) training course, the public health professional on the registration desk said "But you're a physio.....why are you here?"  Whilst we have made some progress in raising our profile in this area we are a long way from being recognised as an integral part of the PH workforce.  This seems strange to me when so much of what we do is about keeping people well, keeping people in work and maximising independence and quality of life.  Surely these are key PH outcomes too?

Last week I attended a public health conference for nurses and AHPs and one of the key things that I took away from it was the realisation that public health is not someone else’s job, if you work in healthcare then public health is part of your job.  Yes, there are people who work exclusively in PH, but PH approaches will only work if they are embedded broadly in a way that can influence the health of populations rather than just individuals. 

The new "Framework for Personalised Care and Population Health" has been developed to help maximise the impact of AHPs (and nurses, midwives and health visitors) in improving health outcomes and reducing health inequalities.  The framework identifies 6 key areas of population health activity, one thing that struck me was just how much we do as physios in these areas already.

 

          Supporting Health, Wellbeing & Independence

       Physios eat your hearts out, this is our bread & butter, show me a physio that isn’t doing this every day!

 

     Healthcare Public Health

This term basically means delivering PH interventions to those who are already in the healthcare system (sometimes called secondary health promotion).  This is something we do a huge amount of, think physio for people with LTCs, people with co-morbidities etc..  Think about our skills in treating a presenting complaint but also advising, managing  & preventing secondary issues.  This is a key area for physios and one that we are firmly recognised as being key players in. 

 

Health Protection

This isn’t traditionally thought of as an area that physios would have a major role in, it usually relates to pre-emptive measures put in place to avoid/limit future problems.  This might include breast screening for women over 50 or immunisations for children.  We do have a role in health protection though, we use valid, reliable measurement tools to predict those at risk of falling and we target treatment based on the results.  We are being encouraged to routinely screen older adults for fraility for example, by using tools such as the 4 meter walk test.  At present we screen as & when we see fit rather than having mass screening programmes.  One screening programme that I would really like to see introduced is routine screening of physical activity levels as part of every Physiotherapy assessment, it would be lovely to think that this might happen in the next 10 years.

 

Making Every Contact Count

This is an important one for us; MECC is an initiative that encourages us to use every healthcare contact for maximum benefit.  This means looking at our existing practice and thinking about how we can integrate key health messages.  The big 4 health messages are about alcohol, tobacco, nutrition and physical activity.  I’d be pretty confident that most physios regularly advise about physical activity but how many of us are confident broaching weight issues, giving nutritional advice or advising on alcohol and tobacco?  Whilst we don’t need in-depth knowledge on these issues we do need some knowledge and we need to know where to send people for more information.  I think this is a real area of potential development for our profession.  And before I jump down off the old soap box I’ll briefly add in that the whole Physical Activity agenda offers massive opportunities for us, we are so well equipped to lead on this (more to come on this too)!

 

Improving the wider determinants of health

      There are still huge inequalities in healthcare and this is something that we all have to work hard to address, it is simply not fair that someone should have poorer health and poorer outcomes based on their postcode.  It surprises me that this doesn't feature more in the design of our services, it's relatively easy to get affluent people better so we should really be targeting hard to reach/hard to treat populations.  I did a systematic review a while ago to see whether deprivation, or socioeconomic status, influenced outcomes in musculoskeletal physio.  It did, unsurprisingly, but what was surprising was the fact that I only found 3 articles to include in the review.  Deprivation can be ranked based on postcode so this data will be collected routinely but it is almost never used, even for secondary analysis in physiotherapy research.

 

     Lifecourse

 

       We do work with individuals over their lifecourse and we have specialist physios for every stage.  With the changing demographic of the UK population I think we will see Physiotherapy for older adults become less of a speciality and more the main stay of what most physios do.  When I say "less of a speciality" I'm not suggesting deskilling, I'm suggesting that more of us will need the specialist skills required for working with older people.  So much amazing PH work in falling for example, this is an area that we are recognised as leaders in, it would be great to think we can emulate this in other areas too.

I think it's fair to say that as a profession we have been slow to engage with PH agendas, I think this might be because there has been a feeling that it’s someone else's job and also that it is additional work that an already stretched physio workforce will be required to do.  I feel pretty confident that neither of these statements is correct, PH principles are already deeply embedded within physiotherapy practice….we just haven’t realised that what we are doing is "public health".

There are very strong messages coming through that we need to engage with PH agendas and I think the first step in this might be thinking about our own practice & identifying the bits of PH work that we are already doing….step two is shouting about them!