Prescribing physical activity as an alternative way of treating physical and mental health problems: interview with Marita Friberg

To support EU Member States in reaching the Sustainable Developmental Goals, the European Commission has established the new expert group “Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases”. The Group sets Public Health priorities and coordinates implementation of evidence-based best practice interventions in other countries. We conducted an interview with Marita Friberg from the Public Health Agency of Sweden, who presented a best practice example on prescribing physical activity for physical and mental health problems, which planned to be implemented in 10 other member states.

PB: Thank you, Marita, for agreeing to participate in this interview. Could you please give us a short summary of your best practice example on prescribing physical activity? How did your project become part the best practice examples?

MF: Our project was suggested by the Steering Group as a best practice example. We developed a method in Sweden (prescribing physical activity), which has been scientifically evaluated and is proven to be as good as medical treatment (to address physical and mental health problems). Prescribing physical activity is used in healthcare, and follows the medical treatment process: the prescriber has to be registered, the process has to be followed-up and documented in a systematic way. The prescriber could be a doctor, a nurse or a physiotherapist. These are the key figures of the method. The evidence-based handbook presents prescriptions for different diagnoses. The treatment is individualised, happening in a dialog with the patient and based on each person’s capacity and motivation.

GB: What can you do if people do not want or cannot afford to buy a membership for a sports facility?

MF: The recommendations in the guidebook only indicate the dosage, not a particular activity. For example, strength-training three times a week or aerobic training four times a week. Then, in dialog with the patient, we discuss what is most convenient, and we try to find the physical activity which suits the person the best. The dialogue is central and essential to the implementation of the best practice. If the cost for gym is too expensive, then you can find other options, such as using your own bodyweight or working out at home. We talk about how you can integrate physical activity in your everyday life. For example, if you are going to your workplace or visit friends, walking, getting off the bus earlier or cycling, all of those would be an option to increase physical activity. Or taking the stairs instead of the elevator. The majority of patients receive prescribed walking. It is not about the exercise itself, it is about physical activity.

PB: …but what if I don’t want to do it alone?

MF: Then the healthcare can inform you of physical activity providers and groups in your area. In some regions, there are even health coaches. If you visit your doctor, she/he can recommend you talk with a health coach, who is usually a trainer or physiotherapist, and the coach can help you further.

PB: In Belgium, GPs have more or less 15 minutes to see a patient. How can this dialogue fit in such a short timeframe?

This is also a problem in most of the countries we have been talking to, because only the doctors are allowed to prescribe. In Sweden, we are using special trained nurses, because doctors often have limited time for a dialogue.  It is cost-effective to use nurses. However, it is important to have doctors on board because they meet the patient and they can suggest the patient to talk to the nurses. Doctors can be the door openers, but they do not have to be the person who has the dialog with the patients.

GB: What is your experience about working with people from lower socioeconomic background? Studies show a social gradient in physical activity.

MF: This is an important issue we have to work on. Also, the adherence to the prescription. We are struggling in Sweden, because prescription for physical activity is an offer that patients can accept or decline. This group more often declines the prescription for physical activity and prefers taking medication. We have to include them somehow, otherwise only those who are motivated will participate in our project. This will increase the inequality gap. So, this it is a future lesson to learn, how can we work with these vulnerable groups.

PB: What do you think would be the struggle to share and implement this project in other countries? The healthcare systems might be completely different.

MF: That is why we need a feasibility study at the beginning of the project. We try to be realistic: it is not going to be implemented on national level. We start small. We will work with actual health professionals on local level, who talk to patients and who want to implement our project. Parallel on the structural level, we need to raise awareness in stakeholder workshops, and show how our method could be integrated in the health care system.

PB: What should be the role of the Steering Group on Prevention and Promotion?

MF: I think the Steering Group has started this project, as they see how important it is. We have 10 participating member states at the moment and about 5-6, who want to join. But, we have a limited budget and limited time. We can start the European implementation in this first project, but the Steering Group has to acknowledge that it will need further support, as you are not going to solve this problem with a three years project. While we start with these 10 participating countries, other countries might see the benefits and would like to join. It is important that we can introduce this method to them as well.

PB and GB: Thank you for your time. We really look forward at seeing how this project will be implemented.

This interview was conducted by Young Gasteiners Petronille Bogaert and Gerg? Baranyi

Economic strategies for health equality (L2)

Building bridges with business and economic development

We hear a common theme at the European Health Forum Gastein – that we need greater levels of multi-sectoral work to tackle health inequalities. This includes private businesses and the “wealth generators” in society, since they too have an influence over the health of populations. Today’s lunchtime session on economic strategies for health equality emphasised the importance of engaging with businesses and economic groups if we are serious about achieving the SDGs by 2030.

Emma Spencelayh from the Health Foundation kicked off this session by highlighting some stark health inequalities from the UK. Major gaps in life expectancy and high levels of childhood poverty were cited; these are issues we may be familiar with, but cannot afford to be complacent about. Clearly, economic growth in high-income countries does not always equate to inclusive growth where everyone benefits. Having a healthy working-age population contributes towards economic prosperity, but there is an onus on us to ensure that available work is fair and decent work, which recognises the labour rights of employees. A few eyebrows were raised when some modern-day workplaces were likened to “sweatshops” and “Victorian workhouses”, particularly in zero-hour contract settings. Calling a spade a spade, perhaps…? If we truly want a healthy and productive workforce, then surely we need to do more to engage with large-scale employers, and encourage them to end unsafe and unfair employment practices.

Fabrice Murtin of the OECD convincingly argued that we could only truly achieve inclusive economic growth, and the SDG targets, if our health policies respond to “deep drivers of inequalities”. Inequitable income distribution has become more and more entrenched in recent years and has occurred in parallel with disparities in educational opportunities and social mobility. But what’s the solution? He asserted that inclusive growth needs real investment in the vulnerable groups who have been ‘left behind’, and business dynamism needs to be supported. There were nods of approval from the audience at the need to challenge the “Winner takes all” mindset that prevails in so many countries. How can we expect to see population-level improvements in health if our financial resources continue to be so unfairly distributed?

Charlotte Ersbøll of UN Global Compact emphasised the need to support businesses in a practical way so that they view the SDGs as real opportunities for growth. As public health professionals, we need to work together with businesses so they consider the health impacts of their activities. We need to encourage and facilitate them to do this, rather than pointing the finger of blame when it doesn’t happen. Although “health is everyone’s business”, it’s unrealistic to expect the corporate world to tackle health-related issues independently. We all need to play a part in “connecting the dots” between relevant stakeholders: healthcare professionals, policy makers, business leaders, economists, marketing experts etc.

A lively discussion ensued on how we can build bridges with the business world, and what practical steps we can take to ensure that politicians respond to the call for more inclusive economic growth. My highlight in this session was learning about the work done by the OECD in developing modern metrics that capture wellbeing and social progress in a more holistic way. We are all too familiar with the challenge of advocating for public health and social interventions, which we can’t adequately evaluate. The OECD has been working to capture, and quantify, what we mean by improved ‘wellbeing’ and ‘social progress’ by developing new indicators such as the Multidimensional Living Standard and Better Life Index. These metrics will allow holistic cost-benefit analyses to be undertaken when new reforms are proposed, and may help to convince politicians and multi-sectoral partners of the true value of such reforms. This year’s conference is about making “bold political choices” to achieve the SDGs… maybe these tools will help us to convince politicians to do exactly that?

From left to right: Charlotte Ersbøll (Senior Advisor, UN Global Compact), Fabrice Murtin (Economist, OECD), Emma Spencelayh (Senior Policy Advisor, The Health Foundation), Fiona Adshead (Expert Advisor, The Health Foundation).

What can be done? Framework for Action on Inclusive Growth. Slide from presentation by Fabrice Murtin (Economist, OECD).

This blog was written by a Young Gasteiner Peter Barret

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