Paths to Health Pedometer Loan Pack Evaluation University of Strathclyde Jane McKay, PhD Joan Forrest Graham Baker Professor Nanette Mutrie Nick Cavill Independent Health Promotion Consultant
INDEX OF FIGURES...II ACKNOWLEDGEMENTS... IV EXECUTIVE SUMMARY...V 1. INTRODUCTION...1 1.1 Background...1 1.2 Paths to Health: Setting the scene...2 1.3 The Loan Pack...4 1.4 Evaluation brief...5 2. METHODS...6 2.1 Overview of research design...6 2.2 Procedures...6 2.3 Problems Encountered...8 3.1 Administrator questionnaires...10 3.2 Participant questionnaire...17 3.3 Step-count data...27 3.4 Focus Groups...28 4. KEY FINDINGS AND RECOMMENDATIONS...43 4.1 Key findings...43 4.2 Recommendations...47 References...50 APPENDICES...52 Appendix 1: Table of site details and summary of response rates...52 Appendix 2: Flowchart of Administrator s Role in the Evaluation...53 Appendix 3:Table of themes identified in administrator and participant focus groups...54 i
Index of figures Figure 1: Percentage occurrence of reason for distribution...10 Figure 2: Percentage response of participants reaction to being offered loan pack...11 Figure 3: Percentage response of the loan pack s usefulness in communicating the benefits of physical activity...11 Figure 4: Percentage of responses of the effectiveness of the loan pack in terms of increasing walking/physical activity levels...12 Figure 5: Percentage response of the ease with which use of the loan pack could be explained to participants...12 Figure 6: Percentage response of the ease in monitoring and maintaining participants continued use of the pedometer loan pack...13 Figure 7: Percentage of responses indicating how administrators received data from participants...13 Figure 8: Percentage of responses of the usefulness of the administration guidelines 14 Figure 9: Percentage of responses indicating whether or not the loan pack could be improved...14 Figure 10: Percentage of responses indicating whether administrators thought the loan pack would have been more successful on a keep rather than a loan basis...15 Figure 11: Percentage of responses of whether administrators would use a similar resource in the future...15 Figure 12: Percentage of responses of the usefulness of the Paths to Health briefing session...16 Figure 13: Percentage response of gender of respondents to participant questionnaire...18 Figure 14: Descriptive statistics of respondents to participant questionnaires...18 Figure 15: Percentage response of participants use of loan pack (in terms of weeks used)...19 Figure 16: Percentage response of participants views on how much they felt the loan pack increased their awareness of the health benefits of walking...19 Figure 17: Percentage response of participants views on how much they felt the loan pack motivated them to become more active...20 Figure 18: Percentage response of the ease of use with which participants found the loan pack...20 ii
Figure 19: Percentage response of how satisfied participants felt with the guidance they received from their health professional...21 Figure 20: Percentage response of whether participants would have been willing to pay for a pedometer had it been on a for sale basis...21 Figure 21: Percentage response of how much participants would have been willing to pay to purchase a pedometer...22 Figure 22: Main participant views on being offered the loan pack...24 Figure 23: Main participant views on how the loan pack motivated them to become more active...24 Figure 24: Main participant views on if anything other than the loan pack had encouraged them to become more active...25 Figure 25: Main participant descriptions of the walking routes used since receiving the loan pack...25 Figure 26: Main participant views on any aspects of the walking areas in their local community that may have prevented them using the loan pack...26 Figure 27: Main participant views on whether the loan pack or information contained within the loan pack could be improved and what recommendations they would make...26 Figure 28: Mean step count and participant numbers on a week by week basis...28 iii
Acknowledgements The research team would like to thank all participants and administrators who gave their time to the Paths to Health Pedometer Loan Pack Pilot. We also wish to acknowledge the contributions and support we received from the Glasgow Physical Activity Forum. iv
Executive summary This evaluation was commissioned to evaluate the Paths to Health Pedometer Loan Pack, an initiative designed to increase walking levels among those who could benefit from becoming more active. Pedometer loan packs, each containing 14 pedometers and supporting materials were distributed to 21 primary health care sites across Scotland. Health professionals at each site were recruited to identify target patients and to issue them with a package, or participant loan pack, containing a pedometer, educational materials and a daily step-count record card. Participants then undertook a 12-week pedometer based walking programme. The evaluation comprised quantitative and qualitative data collection methods. The effectiveness of the loan pack for increasing daily step-counts was investigated via collection of participant step-count data while participants and administrators views and experiences of using the loan pack were examined with the use of questionnaires and focus groups. Overall, the loan pack was perceived to be a simple and effective tool for promoting walking within the primary care setting. Specifically, health professionals viewed the loan pack as a useful resource for communicating the health benefits of increasing levels of physical activity and indicated their interest in using a similar resource in the future. Becoming aware of one s own level of inactivity and the ability to set and monitor goals were among the benefits of the loan pack reported by participants. A number of limitations were identified and future recommendations proposed. Recommendations relate to: the loan pack and supporting materials, including model of pedometer and step-count targets; improved communication and support mechanisms for participants and administrators; and future evaluation directions. v
1. Introduction 1.1 Background Increasing physical activity is now established in Scotland as being a major contributor to improving the health of the nation and walking has been identified as the most likely mode of activity to change the percentage of the Scottish population who are physically active (Wimbush, 1998). Many different forms of interventions have been used to attempt to increase physical activity. Those that have strong support from systematic reviews include informational interventions, behavioural/social interventions and environmental/policy interventions (Kahn et al 2002). However, the Cochrane review on physical activity interventions concluded that more research is required to identify the most effective methods of exercise promotion in the long-term (Hillsdon et al 2005). Pedometers have been employed for many years as valid and reliable tools with which to measure physical activity through walking (Tudor-Locke et al 2002; Schneider et al 2004). Pedometers have been used to record walking levels in interventions designed to increase physical activity (Chan et al 2004; Speck & Looney 2001; Croteau 2004). Whilst many of these studies displayed an increase in walking, the impact and effect of the pedometer were not evaluated. Research evidence suggests that a motivational effect from pedometers is limited. We have investigated the motivational effects of using pedometers combined with a goal-setting programme in other studies (Mutrie et al 2004). Findings suggest that pedometers may not have long-term motivational utility, but that in the short term effectiveness is improved when a goal-setting programme is incorporated (Baker & Mutrie 2005). Despite the limited amount of research, the use of pedometers as motivational tools has been encouraged through national campaigns and promoted through commercial organisations. Whilst the pedometer has obvious potential to be used as a feedback and goal setting tool, guidelines must be produced to inform practitioners of the most effective ways of implementing the pedometer in national walking programmes, specifically in terms of goals, targets and step-count recommendations. 1
Walking the Way to Health Initiative In 2003 WHI launched a Step-o-Meter Loan Pack Campaign, issuing 60 pedometers each to 120 Primary Health Care Trusts across England. Overall the project raised awareness of walking in the local area; the pedometer was found to help increase motivation to walk and the future use of such a project on a greater scale was thoroughly endorsed (Peters, Jarrett & Robinson, 2004). A further influential finding was the positive response to the loan pack from the health professionals involved. One of the few negative findings from the study was the difficulty for some participants in setting up their devices. Partly as a result of this finding, Paths to Health chose a simpler model of pedometer for the current project. It can be concluded that pedometers may provide an additional motivation for walking and that personalised step goals will be more effective for short-term behaviour change in sedentary or diseased populations with low baseline step-counts. Clear methods and strategies for initiating longer-term behavioural change are yet to be identified. 1.2 Paths to Health: Setting the scene Origins Paths to Health was established in September 2001 as part of the Paths For All Partnership (established in 1996). The vision of the Paths for All Partnership is a Scotland of active communities where each community has a network of paths which people want, and are able to use, for recreation and everyday journeys. This will deliver health, community, sustainable transport and economic benefits for Scotland. Paths to Health was established specifically to deliver the health benefits of this vision and secured five year funding from Big Lottery (previously New Opportunities Fund), British Heart Foundation, Scottish Natural Heritage and NHS Health Scotland. The vision of Paths to Health is to encourage inactive people to walk more, with a specific focus on areas with greatest health inequalities. Paths to Health has evolved into a strong brand in its own right and has developed significantly with the injection of funding from the Scottish Executive Health Department over the last two years. 2
Vision and aims Paths to Health s vision of encouraging inactive people to walk more has remained constant and been extended in response to the report Let s Make Scotland More Active (2003). Creating local partnerships to encourage walking in the community has formed the core of their work and since around 2004 the aims have been developed to include: a) Engaging health professionals in promoting walking; b) Developing workplace initiatives to promote walking (not specifically areas with greatest inequalities); c) Supporting other national organisations to support walking for health objectives, such as Living Streets, Sustrans, Ramblers Association Scotland, Greenspace Scotland. Encouraging inactive people to walk more The Pedometer Loan Pack project set out to engage people who might normally be seen as hard to reach by similar projects. These included working age men (who are typically not engaged by such projects), people from more deprived communities and individuals in weight management clinics or those with weight problems. The pedometer was seen to be a tangible product that could help people to monitor their steps and think about ways to become more active. It was considered a practical and easy way for people from varied backgrounds to think about walking as an integral part of their daily lives. In addition, it was seen as something that would appeal to the estimated 50% of the population who do not like the idea of led walks, thus engaging broader sections of the community. Perhaps more importantly, it was thought that using health professionals as a route added credibility to that information. Engaging health professionals One of the major advantages of developing a pedometer project was that it could offer a tangible product for health professionals to use, rather than simply encouraging people to walk more. The Paths to Health team believed that the pedometer could help initiate conversations about walking and engage a new type of patient, resulting either in referral to led walks or to an increase in independent walking. The practical nature of the pedometer loan pack meant that general practitioners and other health professionals could monitor their patients physical activity using an easily accessible tool. 3
1.3 The Loan Pack Administrators received a brief case-style box ( administrator loan pack ) which contained 10 pedometer units each within its own pillbox stating the dose of 1 step to be taken 10,000 times daily. Four additional pedometers were supplied with each administrator loan pack. Participants were issued with their own loan pack which included one of the pedometer units and a small plastic folder containing the pedometer instructions and two leaflets. One of the leaflets provided simple advice on why using a pedometer was beneficial to the individual; it also explained the step-count targets. The other leaflet formed the daily step-count card for participants to record their steps and provided instructions for calculating the average daily step-count at the end of each week, which they reported to administrators over a 12-week period. The pedometer used was the Silva step counter. It focuses only on step-counting (and not calorie counts or distance as other pedometers do) and the daily reset encourages people to do some walking every day and have smaller targets. It has a large screen and a clip for fastening and costs approximately 3.85. This model was selected as a result of the recommendations arising from the WHI evaluation. Daily step count Paths to Health indicated in the literature accompanying the loan pack that, on average, individuals take between 2,000 and 5,000 steps per day in their everyday activity. The accompanying literature also suggested that thirty minutes of brisk walking on most days of the week (the recommended amount of physical activity to benefit health) would add a further 5,000 steps, thus arriving at a total of 10,000 steps per day. They further indicated that this target would be unattainable for many people and their advice in the loan pack was to add 5,000 steps to whatever their normal daily step-count was. Participants were also encouraged to increase their average daily step-count by 500 steps each week. In their view, a target of 10,000 steps was already in the public domain and therefore should be the key goal for most people in the pilot project. 4
Participating sites Following a request for volunteers to participate in the pedometer loan pack pilot scheme, 21 primary care sites were selected from three health board areas (NHS Ayrshire and Arran, NHS Greater Glasgow and NHS Lothian). One or more designated scheme administrators (often, but not always, a health practitioner) co-ordinated the distribution of loan packs at each site, resulting in 27 loan pack administrators in total. Following discussions between Paths to Health and individual site staff, an optimum number of loan pack users was agreed at each site and the appropriate number of loan packs issued. In total, 77 administrator loan packs were issued across the 21 sites. A maximum of 1078 participants could have been recruited if all pedometers had been issued. The research team randomly selected 50% of the sites to receive a Paths to Health briefing on the administrator s use of the loan pack. A summary of the participating sites, number of designated administrators and loan packs received is presented in Appendix 1. 1.4 Evaluation brief The overall aim of the evaluation was to assess the usefulness of the Pedometer Loan Pack as a resource for health professionals and their clients for increasing levels of walking among inactive people in Scotland. The following objectives were developed as a basis for the evaluation: 1. To evaluate the effectiveness of the resource for increasing physical activity through walking 2. To explore health professionals experiences of using the pack 3. To explore patients /clients experiences of using the pedometer and walking programme 4. To identify training and support needs for administering the pack 5. To determine the appropriateness of the primary care setting for using the pack 5
2. Methods 2.1 Overview of research design The evaluation employed a combination of quantitative and qualitative research methods. Study participants included health professionals who administered loan packs at the 21 pilot sites, referred to hereafter as administrators, and loan pack users, referred to hereafter as participants. A detailed summary of the methods is presented below; however, in brief, the effectiveness of the loan pack for increasing daily step-counts was examined via collection of participant step-count data while participants and administrators views and experiences of using the loan pack were examined with the use of questionnaires and focus group discussions. An additional focus group was conducted with Paths to Health staff for the purposes of informing the research team of the background to the pilot scheme. 2.2 Procedures Preparation phase Ethical approval was given both from the University of Strathclyde Ethics Committee and the NHS Central Office for Research Ethics Committees (COREC). Participant information sheets and consent forms were developed along with data collection tools (administrator and participant questionnaires and focus group guides). For confidentiality reasons, it was decided that the research team would not have access to the names of participants and that administrators would mediate contact between participants and the research team. Following the distribution of loan packs to pilot sites, a member of the research team met with individual administrators to brief them on their mediating role in the evaluation. During this briefing session administrators completed informed consent forms and received a package containing participant information sheets and consent forms and a flowchart summarising their role in the evaluation (Appendix 2). Administrators were asked to inform participants about the evaluation and to invite them to take part. On recruiting participants for the evaluation, administrators were instructed to obtain their informed consent and to issue each participant with a simple numerical code. This code was used on all documentation forwarded to the research team for analysis purposes. As outlined in Appendix 2, administrators were then requested to undertake a series of tasks at certain time points including transferring participant step-count data to the research 6
team; transferring questionnaires to participants; completing questionnaires; participating in focus groups; and assisting in the organisation of participant focus groups. Data collection phase Following the briefing of administrators, a member of the research team made regular contact with all administrators to ensure that step-count data were transferred to the research team and to facilitate the general smooth running of the project. Administrators passed on participant step-count data to the research team every four weeks throughout the 12-week walking programme. At approximately eight weeks into the walking programme, administrators were sent questionnaires which they completed and returned to the research team. The questionnaire consisted of a series of closed questions in which administrators selected their responses from five predetermined options, and open questions to which administrators provided written responses. Questions were designed to identify the effectiveness of the loan pack for increasing participants physical activity levels, the ease with which the loan pack could be administered and also any problems and recommendations the administrators had concerning the loan pack. At the end of the 12- week walking programme, administrators were sent participant questionnaires which they forwarded to participants, who in turn completed and returned them to the research team. Like administrator questionnaires, participant questionnaires consisted of a series of closed and open questions designed to explore the effectiveness of the loan pack in increasing participants physical activity through walking, the ease of use of the loan pack and any problems and recommendations the participants had concerning the loan pack. While quantitative data were collected by way of questionnaires, qualitative data were collected via focus group discussions which were conducted by a member of the research team. Five focus groups were conducted in total, three with administrators and two with participants. Focus groups were designed to gain a more in-depth understanding of administrators and participants views and experiences of using the loan pack and explored, for example, views on the loan pack and its materials, problems encountered and future recommendations. Administrator focus groups were held with administrators from each of the three health board areas and were attended by between four and seven individuals. Participant focus groups were held with participants at two pilot sites: Bourtreehill Medical Practice and Glasgow Weight Management Service and were attended by between four and eight individuals. 7
Data analysis phase Step-count data: Due to receipt of insufficient levels of step-count data, it was not possible to conduct statistical analyses to determine whether significant changes in step-counts had occurred over time. Questionnaires: Responses to closed questions were analysed by calculating the frequency of responses for each response option and presenting results in a graphical format. Administrator questionnaire responses were analysed for any significant differences between those who received a Paths to Health briefing session and those who did not using a chi-square statistical test. Written responses of administrator questionnaires were combined with focus group data and analysed following the qualitative analysis procedures described below. Written responses of participant questionnaires were analysed by documenting the main categories of responses to questions and expressing the number of responses within each category numerically. Focus groups: Focus group discussions were inductively analysed following the procedures recommended by Berg (2004). Briefly, following the transcription of discussions, themes were extracted from the data by assigning labels to individual quotations to summarise their meaning. Themes that reflected common threads were then clustered together to form more general categories of themes. 2.3 Problems Encountered A number of difficulties were encountered during the evaluation which should be noted. Firstly, the NHS ethical approval process was considerably more complex and timeconsuming than expected. In short, due to the requirement to collect data from three health board areas, seeking ethical approval from COREC and management approval from the ethics committees of three health boards was protracted beyond expectations. Such requirements are new to researchers and to those commissioning research that involves NHS patients and project planning lessons must be learned from this experience. Consequently, a number of revisions had to be made to the research design. For example, it had been planned to conduct one-to-one interviews with loan pack administrators at each of the 21 pilot sites (as indicated in Appendix 2). However, due to time constraints this was not possible and the overall result was a severe delay in the progression of the evaluation. As a consequence of awaiting ethical approval, Paths to Health delayed distribution of loan packs in case further changes were required to materials being distributed. This further exacerbated the delay, as did the staggered nature of the distribution of packs by administrators and resulted in participants reaching key time points at different times. A final issue concerned the views expressed by some 8
administrators within one health board area. These individuals reported that they had not been adequately informed by their own colleagues about the requirements of their participation in the project prior to agreeing to be involved. 9
3. Results 3.1 Administrator questionnaires As detailed in Appendix 1, 19 administrator questionnaires were returned from a possible 27 (70% return rate). These consisted of eight questionnaires (from a possible 10) from administrators who received the Paths to Health briefing session and 11 questionnaires (from a possible 17) who did not receive the Paths to Health briefing session. The following section presents the results of the closed questions of the administrator questionnaire. A summary figure is presented for each question. Each figure is displayed as a percentage of the total responses and also labels the specific number of responses. The final question relates to the Paths to Health briefing session and therefore was answered only by eight administrators who received this briefing. The section concludes with a summary of the main findings. Categories of participants What categories of patient/clients are you distributing pedometer loan packs to? Reason for Usage Frequency of administrators reasons for distribution Physically Inactive 17 Obesity 14 Diabetes 12 Heart Disease 10 Mental Health Issues 3 Other: - hypertension - musculoskeletal disorders 1 1 Figure 1: Percentage occurrence of reason for distribution 10
Effectiveness for participants What were the participants reactions to being offered the loan pack? Percentage of responses 80 60 40 20 0 0 0 2 Completely negative Mostly negative Mostly indifferent Mostly positive Completely positive Response 13 4 Figure 2: Percentage response of participants reaction to being offered loan pack. How useful is the pedometer loan pack for communicating the benefits of increasing levels of physical activity? Percentage of responses 50 40 30 20 10 0 9 5 5 0 0 Not at all useful Slightly useful Moderately useful Very useful Extremely useful Response Figure 3: Percentage response of the loan pack s usefulness in communicating the benefits of physical activity 11
Overall, how would you rate the effectiveness of the loan pack in terms of increasing walking/physical activity levels? Percentage of responses 80 60 40 20 0 0 Not at all effective 13 4 2 0 Slightly effective Moderately effective Very effective Extremely effective Response Figure 4: Percentage of responses of the effectiveness of the loan pack in terms of increasing walking/physical activity levels Ease of use How easy is it to explain the use of the pedometer loan pack to participants? Percentage of responses 50 40 30 20 10 0 9 7 0 1 2 Not at all easy Slightly easy Moderately easy Very easy Extremely easy Responses Figure 5: Percentage response of the ease with which use of the loan pack could be explained to participants 12
How easy is it to monitor and maintain the participants continued use of the pedometer loan pack? Percentage of responses 50 40 30 20 10 0 6 4 8 1 0 Not at all easy Slightly easy Moderately easy Very easy Extremely easy Responses Figure 6: Percentage response of the ease in monitoring and maintaining participants continued use of the pedometer loan pack How are you receiving data from participants? Percentage of responses 50 40 30 20 10 0 7 2 0 9 1 Phone Face to face E-mail Combination No reponse Response Figure 7: Percentage of responses indicating how administrators received data from participants 13
Administrators advice and recommendations How would you rate the administration guidelines provided with the pedometer loan pack? Percentage of responses 50 40 30 20 10 0 1 Not at all useful Slightly useful Moderately useful 0 9 9 Very useful 0 Extremely useful Response Figure 8: Percentage of responses of the usefulness of the administration guidelines Do you think that the loan pack, including its support and advertising materials could be improved in any way? Percentage of responses 50 40 30 20 10 0 9 8 2 Yes No No answ er Response Figure 9: Percentage of responses indicating whether or not the loan pack could be improved 14
Do you think that the pedometer loan pack would have been more successful if it had been made on a keep rather than loan basis? Percentage of reponses 80 60 40 20 0 13 5 1 Yes No No response Response Figure 10: Percentage of responses indicating whether administrators thought the loan pack would have been more successful on a keep rather than a loan basis Would you use a similar resource with participants again in the future? Percentage of responses 100 80 60 40 20 0 18 0 1 Yes No Depends Response Figure 11: Percentage of responses of whether administrators would use a similar resource in the future 15
Briefing session How would you rate the guidance you received in the briefing session on how to administer the loan pack? Percentage of responses 60 50 40 30 20 10 0 0 Not at all useful Slightly useful Moderately useful 1 3 4 Very useful 0 Extremely useful Response Figure 12: Percentage of responses of the usefulness of the Paths to Health briefing session Summary of results Overall, the loan pack received favourable feedback from administrators in terms of serving as a tool to assist with increasing the physical activity levels of participants. Participants reacted positively to being offered the loan pack and administrators found it both useful in communicating the benefits of physical activity and also effective as a motivational tool to increase walking. Its success is highlighted in that almost all administrators indicated that they would use the pedometer loan pack or a similar resource in the future, except one who indicated that it would depend on receiving a proper briefing session. The administrators reported that they found the loan-pack either moderately easy or very easy in terms of explaining the use of the pack to participants. Administrators used a combination of methods to receive data from participants; however it was obvious throughout the evaluation that there were problems with monitoring and maintaining the participants continued use of the loan pack. This was indicated in the questionnaire with the majority of administrators reporting that this was not easily undertaken. Although the loan pack administration guidelines were established to be useful, administrators were split on whether or not the loan pack could be improved. In addition, most administrators 16
indicated that they thought the loan pack would have been more successful if it were issued on a keep basis rather than a loan basis. The majority of administrators who underwent the Paths to Health briefing session found this session to be useful. However, statistical analysis, comparing the administrators who received the Paths to Health briefing session and the administrators who received no briefing session, found no significant differences in response to any of the closed questions. 3.2 Participant questionnaire Due to severe delays in the distribution of loan packs at some sites, it was impractical to issue participant questionnaires to all 21 sites and so 16 of the 21 sites received questionnaires. In total 88 questionnaires were returned from a possible 335, resulting in a 26% response rate from participants. These consisted of 37 questionnaires (out of a possible 137) from participants in sites that received the Paths to Health briefing session and 51 questionnaires (out of a possible 198) from participants in sites that did not receive the Paths to Health briefing session (Appendix 1). Responses to Closed Questions The following section presents the results of the analyses of responses to the closed questions of the participant questionnaire. A summary figure is presented for each question. Each figure is displayed as a percentage of the total responses and also labels the specific number of responses. 17
The participant sample Gender of participants receiving the pedometer loan pack Percentage of responses 70 60 50 40 30 20 10 0 58 20 10 Male Female Did not specify Response Figure 13: Percentage response of gender of respondents to participant questionnaire Age range of participants receiving the pedometer loan pack Number of Mean age (years) Standard Minimum age Maximum age respondents Deviation (years) (years) 79 50.56 13.63 28 86 Figure 14: Descriptive statistics of respondents to participant questionnaires 18
For how many weeks did you use the pedometer loan pack? Percentage of responses 60 50 40 30 20 10 0 48 25 0 4 11 1-2 w eeks 2-4 w eeks 4-7 w eeks 7-10 w eeks 10+ w eeks Response Figure 15: Percentage response of participants use of loan pack (in terms of weeks used) Increased awareness and motivation How much did the pedometer loan pack increase your awareness of the health benefits of walking? Percentage of responses 70 60 50 40 30 20 10 0 52 1 14 15 6 Not at all Slightly Moderately Very Extremely Response Figure 16: Percentage response of participants views on how much they felt the loan pack increased their awareness of the health benefits of walking 19
How much did the pedometer loan pack motivate you to become more active? Percentage of responses 60 50 40 30 20 10 0 50 19 1 6 12 Not at all Slightly Moderately Very Extremely Response Figure 17: Percentage response of participants views on how much they felt the loan pack motivated them to become more active Ease of use How easy to use did you find the pedometer loan pack? Percentage of responses 60 50 40 30 20 10 0 47 35 1 0 5 Not at all easy Slightly easy Moderately easy Very easy Extremely easy Response Figure 18: Percentage response of the ease of use with which participants found the loan pack 20
How satisfied were you with the guidance you received from your health professional on how to use the pedometer loan pack? Percentage of responses 60 50 40 30 20 10 0 0 Not at all satisfied Slightly satisfied 2 7 Moderately satisfied 50 Very satisfied 29 Extremely satisfied Response Figure 19: Percentage response of how satisfied participants felt with the guidance they received from their health professional Future use of pedometers If the pedometer had been made available on a for sale basis rather than a loan basis, would you have been willing to pay? Percentage of responses 80 60 40 20 0 60 22 6 Yes No No answ er Response Figure 20: Percentage response of whether participants would have been willing to pay for a pedometer had it been on a for sale basis 21
If so, how much would you have been willing to pay? Percentage of responses 40 30 20 10 0 12 18 11 4 4 2-5 5 5-10 Retail cost Have one already Response Figure 21: Percentage response of how much participants would have been willing to pay to purchase a pedometer. Summary Overall the responses to the closed questions of the participant questionnaire were very positive about the loan pack. A number of issues were raised that could be considered for its future implementation. Sixty-six percent of participants who returned the questionnaire were female. It may be that this is not representative of all participants who received the loan pack and only representative of the participants of the evaluation who returned the questionnaire. The average age of the participants was 50.56 years (Males 57.16; females 48.63 years). It is known that at this age the percentage of men and women who are not achieving the minimum physical activity guidelines for health is roughly equal (Scottish Health Survey, 2003). Hence increasing the proportion of men who participate in the scheme should be important in any future implementation of the loan pack. Nearly half of the participants stated that they used the loan pack for a time greater than 10 weeks, although this is not reflected in the step-count data (see page 27), where full 12- week data were obtained for only 16 participants. This highlights the issue raised in the administrator questionnaire regarding difficulties in monitoring and maintaining the participants continued use of the loan pack. Participants were positive about the effectiveness of the loan pack in both increasing their awareness of the health benefits of walking and also in actually motivating them to 22
become more physically active. Participants also reported positively on the guidance they received from their administrators on how to use the loan pack and also on its ease of use, with the vast majority of participants indicating they were either very or extremely satisfied in both cases. The majority of participants appeared willing to purchase the pedometer which supports feedback from the administrator questionnaire indicating that the loan pack would be more successful had it been distributed on a keep rather than a loan basis. According to feedback received, a maximum value of 5 would be an appropriate price and is consistent with the retail cost of the model of pedometer used by participants. However, it should be noted that not all potential loan pack users would be able to afford this. Responses to Open Questions The aim of the open-ended questions in the participant questionnaire was to obtain more in-depth feedback than could have been attained using closed questions. The following section presents the results of the analysis of the responses to the open-ended questions of the participant questionnaire. Each figure presents the key categories of responses obtained and the number of participants who responded in each category. 23
Increased awareness and motivation How did you feel/respond to being offered the pedometer loan pack as a means of improving health? Enthusiastic 27 Categories Good idea More Focused Grateful Empow ered 4 5 9 10 Felt someone cared 3 0 5 10 15 20 25 30 Number of responses Figure 22: Main participant views on being offered the loan pack In what ways did the pedometer loan pack motivate you to become more active? Able to set/monitor goals 21 Categories Realising inactive levels View ing step-counts Other Logging step-counts 5 6 13 16 Acts as a reminder 2 0 5 10 15 20 25 Number of responses Figure 23: Main participant views on how the loan pack motivated them to become more active 24
Has anything other than the pedometer loan pack encouraged you to consider becoming more active? If so, what was it? No 19 Desire to lose w eight 18 Categories Health problems Getting older Public health information 5 5 10 Joining a w alking group 5 0 5 10 15 20 Number of responses Figure 24: Main participant views on if anything other than the loan pack had encouraged them to become more active Walking routes How would you describe the walking routes that you have been using since receiving the pedometer loan pack? Various roads (tow n/city) 36 Quiet roads 17 Categories Off-road trails Parks (tow n/city) Wide variety 3 7 12 Housing scheme 1 0 5 10 15 20 25 30 35 40 Number of responses Figure 25: Main participant descriptions of the walking routes used since receiving the loan pack 25
Are there any aspects of the walking areas in your local community that discouraged/prevented you from using the pedometer loan pack? None 57 Categories Walking alone at nights Darkness in w inter months Bad w eather 3 3 11 Lack of local routes in city 1 0 10 20 30 40 50 60 Number of responses Figure 26: Main participant views on any aspects of the walking areas in their local community that may have prevented them using the loan pack Participants advice and recommendations Do you think the pedometer or the information contained within the loan pack could be improved in any way? If so what recommendations would you make? No changes required 48 Categories Pedometer improvements Other 5 17 Information on local w alking groups 3 0 10 20 30 40 50 60 Number of responses Figure 27: Main participant views on whether the loan pack or information contained within the loan pack could be improved and what recommendations they would make 26
Summary There were no negative responses from participants on being offered the loan pack. The major view identified was that of enthusiasm and other, perhaps unexpected, views such as being grateful and feeling someone cared were expressed. Motivation to become more active was based on the pedometer s capacity to act as a feedback tool and also to assist with goal-setting. Importantly, the pedometer also appeared to greatly enhance participants awareness of their levels of inactivity. A range of categories was identified suggesting that the motivation to become more active cannot be completely attributed to the loan pack. However, this should not be considered as negative feedback; it simply illustrates that the pedometer can be used in a wide variety of contexts such as weight management, aging and various health problems. The most commonly used walking routes by participants were roads in towns and cities. While this could be a result of the geographical location of the sites, additional information regarding local walking routes would allow more variety in their selection, and this could be a useful addition to the loan pack. The vast majority of participants indicated that there were no aspects of their local community that prevented them from using the pack. However, of those aspects that were identified, walking alone at nights was the most common. Therefore, including information regarding local walking groups would appear beneficial. Information on local walking groups was also identified by participants as a possible addition to loan packs. Most participants, however, indicated that the loan pack required no modifications. A number of improvements were suggested relating to the pedometer unit. These included: using a pedometer that resets less easily and having a more secure clip on the pedometer. 3.3 Step-count data Step-count data return was considerably limited. As shown in Appendix 1, pedometers were distributed to 335 participants out of a possible 1078. Of this, the administrators returned step-count data for 122 participants, which equated to a 36% return rate. Seventy (from a possible 137) of the 122 participants were from sites that had received the Paths to Health briefing session and 52 (from a possible 198) were from sites that had not. Figure 28 provides an overview of the step-count data returned to the research team. 27
Week Number of participants Average daily step count step-counts 1 122 5509.70 2 113 5838.04 3 105 6018.50 4 100 6207.39 5 71 6172.59 6 63 6294.46 7 56 6247.93 8 45 6148.27 9 35 6243.69 10 31 6258.19 11 26 7476.23 12 16 6128.50 Figure 28: Mean step count and participant numbers on a week by week basis This figure illustrates the decline in the step-count data received by the research team over time. This decline meant that unfortunately, a statistical analysis of potential changes in step-count levels was impossible to conduct given the extent of the missing data. Substitution methods for missing data were discussed but it was decided that the resulting possible error rates and subsequent reliability of analysis would have severely compromised any significant results. Only 16 participants reported full 12-week stepcount data, however, in the participant questionnaire approximately half of participants indicated that they used the pedometer for a time in excess of 10 weeks. This raises doubt as to whether all step-count data received by administrators was passed onto the research team and highlights the need for more robust data collection methods. 3.4 Focus Groups Analysis of focus group discussions held with administrators resulted in the identification of 91 themes, which were categorised into eight general categories. Fifty specific themes were identified in the analysis of participant focus groups and grouped into seven broad categories. A full listing of all themes identified is presented in Appendix 3. The following section describes the key findings that emerged from focus groups with loan pack administrators and is followed by a discussion of the key findings emerging from participant focus groups. Illustrative quotations are provided throughout. 28
Key findings from administrator focus groups Communication A number of issues were raised relating to communication between Paths to Health and loan pack administrators. These centred around briefing sessions conducted by Paths to Health on how to administer loan packs and communication/administration issues. Most administrators found the briefing helpful in answering queries and increasing administrator competence in using the packs. This supports questionnaire responses in which administrators rated briefing sessions to be at least moderately useful. One administrator commented: It was good to have it reinforced what we were going to do, em, it made me feel more confident in handling the pedometer and pack. Others, however, felt that some answers to questions were not clarified and that they would have benefited from having been talked through the paperwork in more detail. Others felt that the briefing sessions were not necessary as they did not provide any additional information to that provided within the accompanying literature. Some administrators who did not receive a briefing, however, felt that they would have benefited from one. For example, one administrator stated: I would certainly have found it more beneficial to have had a briefing session, em, I think it would have helped us understand more actually sitting down and discussing it might have helped with some problem shooting later on. Some communication/administration issues were raised. One administrator explained that he could not commit the time to distributing loan packs because they arrived several weeks late, at which point his work commitments had increased. Similarly, others commented that they had identified several participants who could have used loan packs but that delays in obtaining packs resulted in those participants missing out. Administrators from Glasgow pilot sites felt that communication from Paths to Health could have been improved throughout the implementation of the scheme: Paths to Health phoned me up once and I think a bit more contact from them to see how we re getting on because basically you ve [member of research team] been the only contact that we ve had. 29
Loan pack contents/design A number of themes emerged relating to the loan pack design, pedometer and supporting materials. Views on the design of the loan pack were generally very positive. Several administrators commented upon the novel idea of the pillbox-style packaging of pedometers and the humorous touch. Such feedback included: I liked the humour, you know, One step 10,000 times a day. I don t know who came up with that, I just thought it was very clever. Indeed, the packaging of the pedometer appeared to evoke more positive reactions from participants than pedometers that were packaged in their standard boxes. One administrator explained: I did notice the difference between handing out pillboxes and standard boxes; they were more excited when they got their dose bottle. Others commented on the visual impact of the design and the effectiveness of the analogy of the pedometer pillbox as a medication or prescription for better health. One administrator also mentioned the value of the male image on the pillbox, which was particularly appreciated by male participants: My male clients liked the picture of a man on the front because often these health promotion things are just women and this chap who is now doing 14,000 steps could relate to this wee man on the front. Several administrators commented on the success of the model of pedometer selected. All administrators agreed that the pedometer was particularly effective due to its simplicity and ease of use. Typical feedback included: They were very easy to use, these particular pedometers. Some you have to set the length of your stride but this one you can use straightaway so that s the beauty of it, its simplicity. Problems with pedometers were, however, encountered. Specifically, it was reported that some batches of pedometers were faulty and that they reset too easily. This was viewed to be a reason for some participants becoming de-motivated and dropping out of the study: I got lots of complaints about pedometers not picking up accurately and people being quite disheartened and people withdrawing from the study for that reason. Another issue was that the pedometer didn t appear to function correctly with certain groups of participants, particularly those who were overweight. It was suggested that this could be due to difficulties maintaining the vertical positioning of pedometers while walking. To resolve this problem many participants resorted to attaching pedometers to their shoes, where they appeared to function more effectively. 30
Supporting questionnaire responses, most administrators commented that the administration guidelines accompanying loan packs were useful. It was noted that the guidelines were easy to follow and that explaining the use of the loan pack to participants was straightforward. Typical feedback included: I think it was very comprehensive, it was quite understandable and easy to read. It s got everything that you need in there and itself it s quite explanatory. However, a few administrators felt that more guidance on the selection of participants was necessary, particularly with regard to patients with chronic diseases. For example, one administrator commented: There was no briefing on selection of clients aside from those who want to increase their activity would all administrators know how to answer questions about cardiac or diabetic clients? Other feedback on the materials contained within loan packs concerned the step-count record card, which was viewed to be too flimsy and consequently easily lost. Positive impact of the scheme The scheme was viewed to have a positive impact in terms of participant reactions and educational and motivational outcomes. Administrators agreed that the loan pack was a great idea with strong potential for improving health. In addition, having something tangible to give to participants was viewed positively, as this quote illustrates: I m really enthusiastic about the possibilities of this. It s great to be able to give something practical to the patients. Administrators working within medical practices commented upon the health benefits associated with the loan pack including mental health and social benefits, as well as its potential for tackling obesity. One practice nurse claimed: I think for the future, because obesity is coming into the general practice contract we re going to find that things like this will probably be increasing so if we can start now and we can identify these at risk patients then it can only help. Administrators reported that reactions of participants to the loan pack were very positive and that in many sites potential users had heard about the packs and had requested to join the scheme. Positive educational outcomes included increased awareness of poor physical activity levels and increased knowledge among administrators of how to assist participants in increasing their activity levels. A practice nurse explained: 31