Heartmoves Long Form PDF Report

Contents
Acknowledgments............................................1
Executive summary..........................................3
1 Introduction ................................................7
1.1 Background............................................7
1.2 Project development................................8
Fitness industry involvement ..............................8
Barriers to exercise participation ........................8
in fitness centres
General practitioner involvement .......................8
1.3 Project management ...............................9
1.4 Project aim and objectives .......................9
Aim ...................................................................9
Objectives ..........................................................9
Concurrent studies.............................................9
2 Methods....................................................11
2.1 The intervention....................................11
Heartmoves training...........................................11
Heartmoves Leader Training Manual...................11
Heartmoves leader training workshops..................11
Heartmoves leader resources...............................12
Pre-exercise assessment form..............................12
Health professional fax back form.......................12
Class attendance log .......................................12
Workshops .......................................................12
General practitioner workshop............................12
Allied Health professionals’ workshop ..................13
Fitness centre managers’ workshop ......................13
Marketing ........................................................13
Public launch................................................13
Demonstrations and presentations .......................13
Direct promotion to general practitioners................13
Newspaper articles .........................................14
Posters and pamphlets .....................................14
Fridge magnets and t-shirts...............................14
2.2 Evaluation.............................................14
Surveys.............................................................14
Fitness centre managers’ survey ..........................14
Fitness centre clients’ survey ..............................14
Process level indicators .....................................15
Quality and safety .........................................15
• Heartmoves leader training ..............................15
• Adherence to Heartmoves training guidelines ..15
• Adherence to pre-exercise..............................15
screening procedure
Acceptability.................................................15
• Heartmoves training ........................................15
• Heartmoves participants...................................15
• Fitness centre managers..................................16
Reach ........................................................16
• Heartmoves participants...................................16
• Fitness centres................................................16
• Telephone line referral ...................................16
• GPs and Allied Health professionals ...............16
• Media coverage..............................................16
Retention ....................................................16
• Heartmoves participants...................................16
Data analysis.....................................................16
3 Results ......................................................17
3.1 Surveys .................................................17
Fitness centre managers’ survey.........................17
Response rate ...............................................17
Fitness centre characteristics ...............................17
Programs offered by fitness centres .......................17
Health risk screening management ......................18
Fitness centre clients’ survey .............................18
Response rate ...............................................18
Characteristics of fitness centre clients ...................18
Self reported cardiovascular risk ..........................19
profile of fitness centre clients
Heartmoves participant survey............................20
Response rate ...............................................20
Characteristics of Heartmoves participants .............20
NSW Health Heartmoves i
Heartmoves NSW Health ii
3.2 Process level indicators ..........................21
Quality and safety ............................................21
Heartmoves leader training ...............................21
Adherence to Heartmoves training guidelines..........21
Adherence to pre-exercise screening procedure..........21
Adherence to low-moderate intensity....................21
Acceptability ....................................................22
Heartmoves training .......................................22
Heartmoves participants...................................22
• Satisfaction with Heartmoves...........................22
• Attendance and cost.......................................22
Fitness centre managers....................................22
Reach ..............................................................23
Heartmoves participants...................................23
Fitness centres...............................................23
Telephone line referral .....................................24
GPs and Allied Health ...................................24
professionals workshop attendance
General practitioner referrals/ ............................24
medical clearance to Heartmoves
Media coverage..............................................25
Retention ........................................................25
Heartmoves participants...................................25
4 Discussion ................................................27
4.1 Quality, safety, acceptability,....................27
reach and retention
4.2 CVD risk factors among ........................29
fitness centre clients
4.3 Low to moderate intensity exercise .........29
classes offered by fitness centres
5. Concurrent study 1 – ..............................31
Cardiac rehabilitation cohort
5.1 Objectives .............................................31
5.2 Methods................................................31
Study design.....................................................31
Data collection.................................................31
Survey........................................................31
Analysis ............................................................32
5.3 Results..................................................32
Response rate and loss to follow-up.................32
Sociodemographic characteristics......................32
Self reported cardiovascular risk profile
of cardiac rehabilitation patients .......................32
Continuation of exercise after rehabilitation .....33
Heartmoves attendance and awareness ................33
Barriers to exercise participation
post-rehabilitation ............................................33
Patients’ report of receiving
secondary prevention........................................34
5.4 Discussion .............................................36
6 Concurrent study 2 – Walking group .....37
6.1 Objectives .............................................37
6.2 Methods ...............................................37
Study design.....................................................37
Data collection.................................................37
Measurement ...................................................37
Questionnaire ...............................................37
Analysis ............................................................38
6.3 Results..................................................38
Response rate...................................................38
Sociodemographic characteristics......................38
of walking group sample
Self reported cardiovascular risk........................39
profile of walking sample
Walking group characteristics ...........................39
6.4 Discussion.............................................39
7. Summary and recommendations...........41
7.1 Summary..............................................41
7.2 Recommendations.................................43
Contents
NSW Health Heartmoves iii
References......................................................45
Appendices .....................................................47
Appendix A
Management and Advisory Committees ..................47
Appendix B
Borg’s Rate of Perceived Exertion (RPE) Scale .......49
Appendix C
Pre-exercise assessment form (PEAF) ......................50
Appendix D
Heartmoves promotional material ...........................53
Appendix E
Body Mass Index (BMI)
and energy expenditure calculations ........................59
Appendix F
Media articles..........................................................60
Contents

Acknowledgments
This project was made possible by the passion and commitment of the investigators, Advisory
Group members and project staff and the partnership between National Heart Foundation of Australia, Hunter Health and NSW Health. The intellectual and visionary support from cardiologists, endocrinologists, nurses, behavioural scientists, exercise physiologists,
fitness leaders, dietitians and fitness managers was also invaluable.
The expertise and support provided by Dr Amanda Nagle, Professor Peter Fletcher, Dr Bruce Bastian, and Ms Kerry Inder were essential to the success and acceptability of the project to both the health and fitness sectors. Further, Dr Kerry Bowen and Ms Melba Mensch provided valuable expertise in diabetes management, and Ms Deborah Huff and Ms Alison Koschel were responsible for the smooth running of the project.
The project team wishes to thank NSW Health, particularly the Nutrition and Physical Activity
Branch for funding this project within its Physical Activity Demonstration Research Grants Program and the fitness industry in the Hunter region for their accessibility and support through data collection.
A final thank you to the Hunter Urban and the Hunter Rural Divisions of General Practice, the
Hunter Area Health Service, fitnessnsw, and the Cardiac Rehabilitation Advisory Committee of
the National Heart Foundation of Australia (NSW Division) for contributing their expertise and support to this project.

Executive summary
Longitudinal studies have shown that physical activity participation is associated with reductions in all cause mortality and has a specific protective effect in reducing coronary heart disease. Physical inactivity whilst being an independent risk factor for cardiovascular disease (CVD), also affects other modifiable risk factors for CVD including type II diabetes, blood pressure, HDL cholesterol and obesity.
Rehabilitation programs involving exercise training and provided by health professionals (eg cardiac rehabilitation) have been shown to be cost effective interventions in reducing mortality, however the transition after rehabilitation to an independent exercise routine is often difficult for patients to maintain in the long term. In addition to this group of clients, the increasing rates of obesity, diabetes, and falls in the elderly highlights the need for low to moderate exercise options, which are safe and appropriate for a significant proportion of the adult population who may also have underlying heart health risk factors. These exercise options also need to be
attractive for those who may be sedentary and for whom the perceptions of fitness centres being for ‘the young, the fit and the beautiful’ may present a barrier to entry.
The Heartmoves model was designed as an innovative intervention that provided accessible
low to moderate intensity exercise programs for the general population, but which could be safely utilised by those who have risk factors for CVD or with existing stable CVD or type II diabetes. Further, the Heartmoves model endeavoured to link health professionals and the fitness industry by promoting integration. Health professionals, in particular general practitioners (GPs), were identified as a key stakeholder group due to their responsibility for
CVD prevention and chronic disease management.
Fitness leaders were chosen as they:
● possess current cardio-pulmonary resuscitation accreditation
● are registered with a state authority (fitnessnsw)
● are covered by professional indemnity and public liability insurance
● are required to complete accredited continuing education courses to retain registration
● are available and accessible throughout regional and metropolitan NSW.
A comprehensive evaluation of Heartmoves was undertaken to evaluate the safety, quality,
reach and acceptability of the program to clients, health professionals and the fitness industry. The evaluation also aimed to determine the program’s ability to increase the proportion of low to moderate exercise classes offered by fitness centres, and the proportion of fitness centre clients with CVD risk factors. Baseline and follow-up surveys of both fitness centre managers and clients were undertaken, in addition to a survey of Heartmoves participants, and an audit of fitness centre records.
The Heartmoves intervention incorporated quality assurance and safety guidelines. The Heartmoves Fitness Leader Training Workshop gained accreditation from fitnessnsw (15 Continuing Education Credits) and the content was approved as accurate by the National
Heart Foundation of Australia NSW Division (NHFA).
Heartmoves workshops were well attended by fitness leaders, with 63% of those trained going on to establish Heartmoves classes. Additionally, the GP continuing medical education (CME) workshops attracted over 71 GPs and a further 66 Allied Health Professionals attended information workshops. The exercise classes were well received by participants, attracting 400
participants with 80% retention rate at six months during the intervention. The Heartmoves programs successfully attracted the target audience with clients being significantly more likely to be over 60 years, retired, obese, and insufficiently active, than usual fitness centre clients. The program was also well received by fitness centre managers with Heartmoves being adopted by 72% of fitness centres in the Hunter. However, the random survey of fitness
centre clients showed that despite the uptake of Heartmoves within the fitness industry, there
was no evidence of a subsequent increase in the proportion of fitness centre clients with CVD
risk factors. It was successful however, in increasing the proportion of low to moderate intensity exercise classes offered by fitness centres in the Hunter.
Heartmoves programs were found to be acceptable to health professionals, with 10% and 14% of Heartmoves clients having attended cardiac rehabilitation (CR) or diabetes education respectively, in the last 12 months (all requiring medical clearance). The audit of Heartmoves records in the fitness centres showed that 26% of Heartmoves clients had a GP clearance
to exercise (5% proactively referred by their GP and 21% responding to the patient’s request for clearance).
Further engaging GPs and Allied Health Professionals in the use of Heartmoves as a safe physical activity referral option may also strengthen the financial viability of low to moderate intensity programs targeting older adults within the fitness industry.
A concurrent study of cardiac rehabilitation programs conducted during the intervention
indicated that while 40% of patients are interested in Heartmoves, 29% were advised (by either GP, CR nurse or Cardiologist) to attend and few (7%) participated in the programs. Again, the role of health professionals in referral and encouraging participants to exercise was highlighted. Similarly, in a concurrent study of walking program participants, few had received referral from their doctor, and self reported participation decreased by 66% over the 12 month period. These findings indicate the need for further investigation into barriers to attendance, and
identification of strategies to increase referrals and to translate referrals into attendance.
The results of this study suggest that Heartmoves has the potential to become a core program within the fitness industry and that combined with the other dissemination components, can provide a capacity building model for delivering safe, appropriate and accessible physical activity resources to the local community. The acceptability of Heartmoves to health professionals suggests that Heartmoves has the potential to be utilised as an appropriate referral option for area health service rehabilitation programs as well as in GP developed Enhanced Primary Care plans. However, further work is required to identify the barriers to ‘transition’ from medically supervised to community based non-medically supervised
exercise programs among clients. There is also a need to develop tools and resources to enable health professionals, particularly GPs, to take a more proactive role in referring clients to appropriate and safe exercise options.
Heartmoves provides a safe community based exercise program, available at low cost to the
public, delivered by registered, specially trained and accredited fitness leaders, and can potentially link with health professionals. Numerous opportunities to further promote and increase participation in physical activity programs such as Heartmoves exist.
Further investigation is required into strategies to engage health professionals in physical activity promotion, beyond existing strategies such as workshops and script pads.
From the evaluation of Heartmoves and the concurrent studies, the following recommendations are made:
1 Fitness centres are an appropriate setting for the provision of specialist physical activity programs, however, marketing strategies to engage the fitness industry should focus upon the financial viability and potential of such programs in fitness centres.
2 Further strategies, aside from workshops and script pads, to engage health professionals in
the promotion of, and referral to, physical activity programs need to be investigated, particularly the development of eligibility guidelines and streamlined referral and clearance tools.
3 The linkages between Heartmoves and other health professional programs (such as Enhanced Primary Care planning, Chronic Disease Management Programs, diabetes education and falls prevention initiatives) need to be explored.
4 Social marketing strategies to promote safe low to moderate intensity exercise programs should be multi-component to ensure wide coverage and include a centralised listing of locations of such programs.
5 Collecting data about participants’ reasons for ‘dropping-out’ of programs would provide
valuable information to inform future programs.
6 Collecting data about fitness centres, or other provider organisations and the successful
launches of the program as well as the reasons for discontinuing such programs would provide
valuable information to inform future programs.
1.1 Background
Cardiovascular disease (CVD) accounted for 42% of all deaths in Australia in 1996 and 12.5% of the problems managed by General Practitioners (GPs).1 Eighty percent of Australians have at least one modifiable risk factor for CVD, such as diabetes mellitus, hypertension, hyperlipidaemia, overweight or obesity, and tobacco dependence. At highest risk of further cardiovascular events (stroke and heart attack) are those with existing heart disease. The most
prevalent population risk factor for CVD however, is insufficient physical activity, with almost 50% of the population failing to meet recommended levels.
During the past five years, new epidemiological data have stimulated a strong interest in the promotion of
physical activity as an achievable public health strategy for improving health and well-being. There are clear
recommendations for moderate physical activity from the NSW Chief Health Officer and key professional
bodies such as the Centres for Disease Control, American College of Sports Medicine3 and the
American Heart Association.
For coronary heart disease and stroke, there is strong evidence of the benefits of regular exercise.
There is also a strong relationship between increased physical activity and decreases in other risk factors
for CVD (ie hypertension, hyperlipidaemia and obesity or overweight).  There is also overwhelming
evidence that regular exercise is beneficial in the post rehabilitation phase of CVD and there is mounting
evidence for health benefits in relation to type II diabetes, osteoporosis, and arthritis.
Physical activity can be a successful adjunctive, non pharmacological treatment for these conditions.
Physical activity interventions in ‘at-risk’ individuals, including those discharged from hospital with a cardiovascular diagnosis, and those with risk factors for CVD but not yet manifest disease, have the potential to reduce mortality and
morbidity from cardiovascular disease. In the Hunter region of NSW, there is an estimated 2,500 CVD
discharges per year from public hospitals.
Currently in the Hunter region of NSW, patients who have been hospitalised with a cardiac event
have the opportunity to participate in a Phase II rehabilitation program, which is usually conducted
in the outpatient setting over a five to six week period. However, despite the evidence that regular
exercise is beneficial in the post rehabilitation phase of cardiovascular disease, there are limited safe
community based, non-medically supervised exercise programs to assist patients in maintaining
their participation in regular physical activity.
People in these at-risk groups are often cautious about exercise; believing that it might put them at
further risk. Indeed, almost half the respondents in a small Australian survey of retired adults stated that
they had been told by a medical practitioner to restrict their physical activity.8 Most of these respondents cited
hypertension, arthritis, and angina as reasons for not exercising, when in fact all of these conditions
could be improved with regular exercise.
Seventy percent of patients discharged after a cardiac event are classified as low risk of future events and
therefore do not need ongoing medical supervision to exercise. Many of these patients are not compliant
with recommendations to continue with an exercise program without the ongoing support from a group
leader. An opportunity therefore exists for low to moderate physical activity programs to be offered in
the community which would be available to everyone, but which would be specifically safe for clients with
stable CVD or with risk factors for CVD, including diabetes (especially those who had participated in
Phase II cardiac rehabilitation).
1 Introduction
1.2 Project Development
Fitness industry involvement
After considering issues of access, equity and sustainability, fitness centres were identified as an appropriate community setting to provide a low to moderate intensity exercise program, such as Heartmoves. Fitness centres have an acknowledged role in the provision of physical activity programs, with the advantages of central location and being
serviced by public transport. Fitness leaders were considered appropriate Heartmoves leaders, due to their distribution in the community, established expertise in delivering exercise programs, and their current cardio-pulmonary resuscitation accreditation.
Additionally, fitness leaders are registered with a state authority (fitnessnsw) that provides professional indemnity insurance and requires accredited continuing education courses to retain registration.
Barriers to exercise participation in fitness centres Older adults targeted by programs like Heartmoves may perceive a number of barriers to physical activity participation in fitness centres. For example, community perceptions and certain marketing formats within the fitness industry concerning the type of programs being offered (eg ‘go hard or go home’) and the type of participants utilising fitness centres (ie ‘the young, the fit and the beautiful’) are potential barriers.
Further, programs could be perceived as high intensity and requiring high levels of fitness with potentially lethal consequences for those with CVD or diabetes.  These perceptions are likely to act as barriers to participation among the at-risk target group and to health professionals seeking to refer clients to safe and appropriate physical activity.
The fitness industry has shown interest in altering this image so that ‘ordinary’ people would feel
comfortable exercising in their facilities. Although some centres have broadened their focus to include programs for groups such as pregnant women or young mothers, the industry has not yet fully explored the potential of niche marketing for special populations.
Barriers to exercise participation are not limited to fitness centres. Surveys have repeatedly shown that large groups of the population do not exercise because they have ‘nowhere to exercise’ and ‘no-one to exercise with’.  Additionally, safety is a particular concern for women, who seem to prefer ‘aerobics’ type activities rather than walking or jogging, because
these activities are offered in a safe environment.
Among the insufficiently active population, poor health, fear of injury, being too fat and having no equipment have also been identified as barriers to engaging in physical activity.
In the promotion of physical activity, research suggests that marketing of specific exercise programs is
more successful than offering general encouragement to participate in activity.
Programs that involve low travel time, low expenditure and little disruption of other activities are more likely to facilitate maintained participation in physical activity.
General practitioner involvement
General practitioners (GPs) were identified as one of the key stakeholder groups for Heartmoves due to
their responsibility for managing secondary prevention of CVD and increasing involvement in chronic
disease management (including appropriate advice and prescription of physical activity). Currently, there is under utilisation of fitness centres as a referral option for physical activity by GPs. This may be due to a history of poor perceptions in both sectors, which have impeded the useful flow of expertise, referrals and communication.
The Heartmoves GP Working Group of the Advisory Team identified a number of issues associated with GP
referral to fitness centres. In particular, concerns were raised about the lack of:
● GP awareness of low intensity options in the fitness industry
● information resources (eg a pamphlet) to distribute to patients about local programs
● feedback from fitness leaders about any adverse reactions or symptoms experienced by the client during exercise
● GP knowledge about which categories of cardiovascular conditions were unsuitable for exercise prescription, even at a low to moderate intensity.
Introduction
Further issues identified with GP referral of clients to fitness centres included:
● concerns about fitness leader accreditation and training to provide specific programs for participants with or at risk of heart disease or diabetes
● concerns about pre-activity screening
● the increasing requests for GPs to remember and deliver an increasing number of health messages.
Since 80% of the population visit their GP at least once a year, well-informed GPs have the
potential to opportunistically screen for physical inactivity among patients and prescribe physical
activity. Recent research has shown that patients who receive a written prescription for physical activity and
some patient information material from their GP, are 1.6 times more likely than controls to increase their
total physical activity by 60 minutes per week at six to ten weeks.
Research exploring how best to engage GPs in the prescription of physical activity is now being explored. General practitioners appear to be effective in initiating physical activity participation, but other strategies such as the development of appropriate programs is needed to capitalise on this initial change and enable sustained behaviour in the longer term.
1.3 Project management
The Heartmoves project was managed by a multidisciplinary team, which reflected a collaborative partnership between the health and fitness industries (see Appendix A).  Funded by a NSW Health Physical Activity Demonstration Research Grant, the initiative built on the strong partnership already established between the Hunter Area Health Service and the
National Heart Foundation of Australia (NHFA) (NSW Division, Hunter Branch).
The project manager was based at the Heart Foundation along with one of the project staff, whilst another project officer was based at John Hunter Hospital. The project management team (see Appendix A) met fortnightly, while the larger
advisory team (see Appendix A) met three times during the project.
Ethics approval for the project was granted by the Hunter Area Health Service’s Ethics Committee.
1.4 Project aim and objectives
Aim
The aim of the Heartmoves project was to develop and implement an innovative and sustainable exercise program that met the needs of older clients, particularly those with, or at risk of CVD, which was acceptable to both the fitness industry and referring health professionals.
Objectives
The objectives of the Heartmoves project were to:
1 Evaluate the Heartmoves intervention in terms of its:
– quality and safety
– acceptability
– reach
– retention.
2 Determine the intervention’s effectiveness in increasing the proportion of fitness centre clients
with CVD risk factors by 5% from baseline to follow-up.
3 Determine the intervention’s effectiveness in increasing the proportion of low to moderate intensity exercise classes offered by fitness centres in the Hunter region from baseline to follow-up.
Concurrent studies
In addition to the Heartmoves intervention, two concurrent studies were undertaken in parallel.
The first followed a cohort of clients participating in cardiac rehabilitation for nine months to determine participation in physical activity, and the second study examined the extent and nature of participation in structured walking programs in the Hunter during the intervention period. The results of these concurrent studies are reported in Sections 5.3 and 6.3.
Introduction
2.1 The intervention
The intervention was designed at a workshop of the project Advisory Team, and included a number of components.
Heartmoves training
The Heartmoves training and accreditation program for fitness leaders was developed by a working group that
included representatives from:
● fitness centres
● fitness leader training providers (Department of Sport and Recreation, TAFE and fitnessnsw)
● providers of assessment and referral services for at-risk individuals (diabetes education, cardiac
rehabilitation and Divisions of General Practice)
● the target group (at-risk individuals).
Heartmoves Leader Training Manual
A team of experts drawn from the Advisory Team developed the training manual for Heartmoves leaders, which was based on NHFA’s Exercise for people with Heart Disease (guidelines for the prescription and conduct of non-medically supervised, community based exercise programs). The draft document was then circulated to experts in endocrinology, cardiology and exercise physiology for comment. The NHFA’s NSW Cardiac Rehabilitation Advisory Committee also reviewed the accuracy of the training manual’s content.
Heartmoves leader training workshops
Two workshops that followed the training manual exactly, with 10-12 participants each, were developed and delivered over 2.5 days in Area Health Service facilities. The cost to participating fitness leaders was $350, which was in accordance with current market prices. The course was designed to provide participants with a basic understanding of the nature of, and
current treatments for, CVD and diabetes, with emphasis being placed on the ongoing self-management of chronic illnesses.
The health professionals and solicitor who delivered the training discussed the -

i)         increases in risk and benefit of exercise among clients with CVD or diabetes, and

ii)        need for concomitant risk assessment and management.

The session delivered by the solicitor was a crucial component of the training program and highlighted the need for -
a)        adherence to training guidelines and professional standards in confidential record keeping;
b)        retaining documentation from health professionals, and
c)        adherence to the pre-exercise screening protocol within Heartmoves.
A fundamental element of the training was to affect attitudinal change among fitness leaders.
This attitudinal change involved redefining the perceptions of what constituted a ‘good’ leader within the Heartmoves program (eg keeping the intensity low, encouraging people to perform at their own level of perceived exercise intensity). Further, concepts of what was a ‘good’ Heartmoves participant were explained (eg one who only exercises at their
own (moderate) rate of perceived exertion, takes frequent rest stops as self indicated and alerts the leader to any signs of exercise intolerance). Fitness leaders utilised the practical components in the training program to work up and demonstrate
their own Heartmoves classes, which adhered to the following training guidelines:
● participants are guided to work only at a Rate of Perceived Exertion of 3-5 (moderate) on the
modified 10 point Borg Scale (see Appendix B), about 50-70% of Maximum Heart Rate
● classes are open to everyone to exercise in a social, fun and safe environment at a low to moderate intensity
● classes are specifically designed to be safe for those with or at risk of cardiovascular disease and diabetes
● class size is recommended to be limited to 25-30 (even smaller in the early phases of establishing a group)
● class format consists of 4 components:
– warm-up (10mins)
– conditioning/strength (10-15mins)
– endurance (10-15mins)
– cool down (10mins).
2 Methods
● participants are encouraged to work at their own pace and use chairs for rests within a session
● leaders should develop different levels or versions of specific exercises for use with individuals with
limitations (eg seated versions of an exercise)
● leaders should overtly and regularly encourage exercising only at the moderate level
● music appropriate for the age group used as background (approximately 120-130 beats per minute)
● all participants must complete a pre-exercise assessment form (PEAF) prior to participating
in a Heartmoves class (see Appendix C)
● leaders should advise appropriate participants (as indicated on their PEAF) to visit their GP
for medical clearance to exercise
● referring health professionals should be informed of progress (using the health professional fax back
form) at regular intervals if requested
● leaders should display the safety protocols (posters provided), for the management of hypoglycaemia and chest pain and have a rehearsed safety routine in the event of an incident (eg handy cards indicating specific actions for members of the class, such as front desk contact of ambulance, notification of GP, waiting at the front to direct the ambulance)
● leaders should have glucose tablets readily available (or jellybeans) for diabetics
● classes must have a mandatory ten minute warm up period at the beginning of a class (if late then
a participant may not participate until completing
this component) and a mandatory ten minute cool
down period at the end. Additionally there should
be a social 10-15 minutes at the end to enable
feedback on the intensity and work rate and
potential signs of intolerance
● within these guidelines, leaders may create
multiple varieties of exercise programs including
aqua, circuit, floor aerobics, games etc.
Fitness leaders were also invited to attend a local
cardiac rehabilitation program for one session as
an observer to witness the types of exercise being
delivered in that setting. They were also invited to
attend one session of a local diabetes education
program for similar experience.
Heartmoves leader resources
A number of supportive resources were developed
specifically for the Heartmoves leaders and included
a pre-exercise assessment form, a health professional
fax back form, and a class attendance log.
Pre-exercise assessment form
The pre-exercise assessment form (PEAF)
(see Appendix C) was modified from an industry
screening tool. The modifications ensured that
the screening tool adhered to the current US and
Australian guidelines13,14 for identifying individuals
requiring medical clearance before participating
safely in exercise at a low to moderate level. The
aim of the screening tool was to systematically identify
those individuals with a chronic illness and advise
them to check with their GP prior to exercising
and seek medical clearance to exercise. The PEAF
was kept in the records of the Heartmoves leaders along
with any referral or clearance from GPs.
Health professional fax back form
The fax back form was designed to enable
Heartmoves leaders to send information to GPs
and allied health professionals in a standard way.
It provided information to GPs and Allied Health
professionals about attendance and any reported
symptoms of exercise intolerance among participants
they had referred to the program. Permission was
gained from the participant to transfer information
to health professionals.
Class attendance log
The log enabled standardised record keeping across
leaders and was considered appropriate professional
behaviour for improving risk management and
thereby minimising risk to the leader.
Workshops
General practitioner workshop
A continuing medical education (CME) workshop
accredited with nine CME points was developed
and delivered in collaboration with the Hunter
Post Graduate Medical Institute. Two workshops
were delivered, one each to the Rural and Urban
Divisions of General Practice. The workshops
attracted sponsorship from pharmaceutical companies
and were free for participating GPs. Presenters
included a National Heart Foundation (Hunter)
Methods
representative, and a cardiologist and endocrinologist,
both of whom were members of the Advisory Team.
The workshops were titled Physical Activity and the
Management of Cardiovascular Disease and Diabetes
and presented information about the:
● physiological and clinical evidence basis for
the role of physical activity in managing specific
chronic illnesses
● population evidence for physical activity and health
● behavioural evidence for the GP’s role in the
promotion of physical activity
● Active Australia messages
● Heartmoves program (which included
a demonstration)
● local walking programs.
GPs were also provided with an ‘Active Script’
pad12 and Heartmoves information pamphlets, which
included a locality guide of accredited leaders and
their contact details.
Allied health professionals’ workshop
As many of the target group patients would be
seen by allied health professionals through outpatient
clinics, community health centres and home visits,
it was considered important to provide these health
professionals with a Heartmoves training opportunity.
Therefore, a half-day workshop was presented with
invitations and fliers sent to the Heads of all Allied
Health Departments within the Hunter Area Health
Service (HAHS). The workshop was again presented
as Physical Activity and the Management of
Cardiovascular Disease and Diabetes, and again
experts from the specialties of endocrinology
and cardiology were among the presenters.
Each attending health professional received a
modified Active Script pad (including an option
to refer to a GP for clearance to exercise), and a
recommendation to exercise pad. The program for
the workshop also included presentations on two
community-based walking programs, Walking for
Pleasure (Department of Sport and Recreation)
and Just Walk It (NHFA). A demonstration of a
Heartmoves class was also included in the workshop.
Fitness centre managers’ workshop
Fitness centre managers were invited to attend a
half-day workshop where Heartmoves and Active
Australia information and resources were provided.
The appropriateness of the Heartmoves program to
at-risk clients was discussed, with further information
presented at the workshop including:
● statistics on the current levels of inactivity and
cardiovascular disease to illustrate the size of the
potential target market
● the NSW Chief Health Officer’s current message
of the benefits of moderate intensity exercise
● the proposed involvement of health professionals in
a referral and feedback mechanism with accredited
fitness leaders
● the specific exercise needs of individuals with
cardiovascular disease and diabetes
● the importance of risk management when
exercising with at-risk clients.
Marketing
As Heartmoves was open to all population groups,
not just at-risk groups, a social marketing component
was included as part of the intervention.
Public launch
The public launch of Heartmoves during Heart
Week in 1999 involved three shopping centre
demonstrations and media releases about the
importance of physical activity and heart health.
Demonstrations and presentations
Heartmoves demonstrations and presentations
occurred at individual fitness centres and at the
Seniors Expo, with individual fitness leaders
providing free first session passes for potential
customers. Information about Heartmoves was also
incorporated into the general health promotion
of the NHFA in the Hunter region during
community talks and presentations.
Direct promotion to general practitioners
A pharmaceutical company offered to distribute
Heartmoves pamphlets and the Active Script pad to
GPs during their visits, as a value added program.
Methods
Newspaper articles
Briefing documents were supplied with photographs
of Heartmoves classes to journalists at relevant times
such as Seniors Week and Heart Week (see examples
of media coverage in Appendix F).
Posters and pamphlets
The Heartmoves public information pamphlet
(see Appendix D) and locality guide, supplied free
of charge to GPs and allied health professionals, were
also available for purchase by the fitness leaders (for
their own marketing initiatives). Heartmoves program
posters with space available for writing in specific
contact and class details were also distributed.
Fridge magnets and t-shirts
A plain white t-shirt with the Heartmoves logo
on the front was printed and supplied, at a cost
of $10 to fitness leaders for sale to their participants.
Additionally, a small magnet with the Heartmoves
logo was designed for use by fitness centres on
their class schedule display boards (see Appendix D).
This enabled consistency of the brand recognition
by the public.
2.2 Evaluation
Baseline and follow-up cross sectional surveys of
fitness centre managers and fitness centre clients were
used to determine the intervention’s effectiveness in:
● increasing the proportion of fitness centres offering
low to moderate intensity exercise classes
● increasing by 5%, the proportion of clients with
CVD risk factors exercising in fitness centres.
In addition to these surveys and a survey of
Heartmoves participants, a number of process
level indicators were used to assess the quality,
safety, acceptability, reach, and retention rates
of the Heartmoves program.
Surveys
Fitness centre managers’ survey
To determine Heartmoves effectiveness in increasing
the proportion of low to moderate intensity exercise
classes offered by fitness centres in the Hunter,
a baseline survey of fitness centre managers was
conducted between September and November 1998
with a follow-up survey conducted one year later.
The follow-up survey occurred four to six months
after the launch of the Heartmoves program in
the Hunter region. The baseline survey provided
information about the initial nature of fitness centres
in the Hunter and the follow-up measured any
changes after the launch of the Heartmoves program.
The surveys were conducted by telephone and
included questions about characteristics of the fitness
centre, staff profile, types of programs offered, and
procedures for health risk screening. All fitness
centres and personal trainers with businesses
listed in the Yellow Pages in the Hunter region
were eligible for inclusion in the study.
Fitness centre clients’ survey
A baseline and follow-up survey of fitness centre
clients was conducted to determine Heartmoves’
effectiveness in increasing the proportion of fitness
centre clients with CVD risk factors by 5%.The
baseline, self-complete survey of fitness centre clients
was conducted between September and November
1998 (before the introduction of Heartmoves)
and the follow-up survey exactly one year later.
The baseline and follow-up surveys were identical
except for an additional question about Heartmoves
participation in the follow-up survey. Cross sectional
sampling on a randomly selected weekday ensured
that each fitness centre was surveyed for one day
randomly selected at both baseline and follow-up.
The questionnaire collected information about
sociodemographic characteristics (including age,
gender, marital status, education, employment, and
country of origin). It also collected information
about cardiovascular risk profile including:
● participation in physical activity (see Appendix E)
● smoking status
● body mass index (BMI) (see Appendix E)
● family history of CVD and previous history of
CVD risk factors (diabetes, high blood pressure,
previous stroke or heart problem and high
cholesterol).
Knowledge questions regarding physical activity
messages were also contained in the survey.
Methods
NSW Health Heartmoves 15
On the data collection days, research staff from the
NHFA set up an ‘information booth’ and distributed
surveys, information, and consent letters to each
eligible person upon entering the facility between
8.00am to 12.00pm and 2.00pm to 6.00pm.
Managers had been previously informed about the
data collection protocol and were given 24 hours
notice of the data collection day for their centre.
An automatic counter was used to record the total
number of people entering the exercise area of the
fitness centre. People who were obviously not there
to exercise were excluded from the count (ie sales
representatives in suits, parents watching school sports,
students in school uniform and staff). Fitness centre
managers provided a ‘prize’ of a partial membership
for one client of their centre who completed the
survey. Participants were able complete the survey
on the day, or nominate for a telephone interview
at a convenient time.
Process level indicators
Quality and safety
Heartmoves leader training
The quality indicators for the Heartmoves leader
training were the ability of the manual and course
content to gain endorsement by the NHFA, and the
ability of the training program to gain accreditation
from fitnessnsw.
Adherence to Heartmoves
training guidelines
Two quality assurance (QA) audits of each fitness
leader were conducted during the program, and
involved two members of the training team observing
a Heartmoves class and rating the leader’s adherence
to the training guidelines. The first QA audit occurred
approximately two to four months after the leader
had completed their training at a mutually agreed
time. Personalised feedback about the leader’s
adherence to Heartmoves guidelines was provided
as a form of positive feedback in this first audit.
Leaders were also provided with a collated summary
of the average scores on each QA item for all leaders
in the Hunter, enabling them to see their own score
in relation to the average. Six weeks after the initial
feedback was provided, the second QA audit was
conducted by the same team with the timing of
this visit unannounced.
Adherence to pre-exercise
screening procedure
During a records audit at fitness centres, the following
indicators were counted:
● number of participants on the Heartmoves
attendance records who had a completed PEAF
● number of participants whose PEAF indicated
a cardiovascular risk profile, for which medical
clearance was advised
● number of PEAFs that had a written GP
or allied health professional referral/clearance
form attached.
In addition, the date on the PEAF and the date
on the GP referral were recorded. This enabled
a calculation of whether the GP had initially
referred the participant or whether the participant
had approached the GP for a medical clearance
to exercise.
Acceptability
Heartmoves training
The indicators of the acceptability of the Heartmoves
training program to fitness leaders were:
● number of registered fitness leaders completing the
Heartmoves Training Program
● proportion of accredited Heartmoves fitness
leaders who established a Heartmoves program
in the Hunter after completing their training
(the yield of the training program).
Heartmoves participants
A survey of Heartmoves participants conducted
nine months after the launch of the program
collected data about sociodemographic and attendance
characteristics, and program acceptability. Heartmoves
leaders were requested to either give or mail out the
survey, with a reply paid envelope and information
letter, to all participants who had ever enrolled in their
Heartmoves classes. This included former participants
who had dropped out and those who were still
involved but just absent that week.
Methods
The Heartmoves participants’ questionnaire
used the same core questions as the fitness centre
participants’ survey. Additional questions included
in the Heartmoves participants’ questionnaire
collected information about:
● how they became aware of Heartmoves
● how often they participated
● whether they had completed a cardiac
rehabilitation program or a diabetes education
program in the last 12 months
● their satisfaction with the program.
Fitness centre managers
Baseline and follow-up surveys of fitness centre
managers (described previously) included
questions about:
● barriers to the development of programs for
special populations
● barriers to the implementation of Heartmoves*
● the potential of Heartmoves*.
Reach
Heartmoves participants
The survey of Heartmoves participants included questions about radio, TV, and newspaper promotions,
and how the participant found out about Heartmoves.
Fitness centres
Nine months after the public launch of Heartmoves a research staff member visited each fitness centre and determined the:
● number of fitness centres delivering at least one Heartmoves program
● total number of individual Heartmoves programs offered.
Telephone line referral
In a combined print media advertising initiative
(jointly funded by fitness centres) and a Heartmoves
editorial that ran in the Newcastle Herald, the NHFA
telephone number at the Hunter office was given as
the number to call for information. The names and
phone numbers of those who responded were
logged and a Heartmoves pamphlet containing
the locality guide was mailed to each caller. After
three months these callers were telephoned and asked
whether they had received the pamphlet, attended
a fitness centre, or were currently participating in
a Heartmoves program. This provided a response rate
to the media coverage and an overall yield into the
Heartmoves program from telephone inquiries.
GPs and Allied Health professionals
GPs’ and allied health professionals’ interest in the
Heartmoves program was assessed by the number
of GPs and allied health professionals attending the
relevant workshop. Further, pro-active referral of
clients from GPs and allied health professionals
to the program was calculated.
Media coverage
Local monitoring of daily and weekly newspapers
was conducted.
Retention
Heartmoves participants
An audit of participant records kept by Heartmoves leaders was conducted to determine the:
● number of participants who had ever enrolled in Heartmoves
● proportion of these ‘ever enrolled’ participants, who were still exercising in Heartmoves in the
two weeks preceding the audit (ie had attended at least one Heartmoves session during the preceding two weeks).
Data analysis
Frequencies and proportions were calculated for
descriptive data using Stata statistical package –
Version 5. Differences between baseline and follow-up in the proportion of at-risk participants exercising in
the fitness centres were analysed using Chi Square tests. Continuous data were analysed using ANOVA.
For non independent samples the McNemar’s Chi Squared test was applied to matched data points from
Baseline to Follow-up. Refer to Appendix E for calculations of BMI and ‘adequate physical activity’.
Methods
* Follow up survey only
Table 3.1 Programs offered by fitness centres
Lower intensity
• yoga/stretch/relaxation
• active over 50s
• Heartmoves
• Aqua
32%
48%
0%
28%
45%
82%
64%
22%
1.29
8.00
14.00
0.33
0.260
0.005*
0.001*
0.560
Programs offered
Baseline
(n=25)
Follow-up
(n=22) X2** p
Higher intensity:
• beginners circuit
• advanced aerobics
• beginners step
• advanced step
• high impact aerobics
• fat burners/weight loss
• pump
• new body
72%
80%
76%
80%
60%
88%
68%
84%
68%
68%
67%
73%
64%
86%
77%
50%
0.14
3.00
0.33
0.33
0.00
0.20
0.11
6.40
0.700
0.080
0.560
0.560
1.000
0.650
0.740
0.010*
* Significant difference between baseline and follow-up surveys at p<.05.
** McNemar’s Chi Squared analysis performed on matched pairs (with data at both times).
3.1 Surveys
Fitness centre managers’ survey
Response rate
Of the 28 fitness centres in the Hunter, 27 of
the managers participated in the baseline survey.
At follow-up, of the 25 still operational centres, 23
managers participated. The response rates for baseline
and follow-up were 96% and 92% respectively.
Fitness centre characteristics
The survey of fitness centre managers in the Hunter
showed that the mean:
● length of time in operation for the centres was 13 years
● length of time the manager had been managing the centre was three years
● number of individuals estimated to be participating in exercise each week at the centre was 300 at baseline and 350 at follow-up.
At baseline, fitness centre managers in the Hunter
reported employing 452 fitness leaders, with the
majority (69.9%) being employed on a casual basis
(11.5% part time and 18.5% full time). The main
barrier to developing programs for special populations
such as people with heart conditions, identified by
the managers at baseline, was lack of trained staff
(84% of managers, which dropped to 48% of
managers at follow-up).
Programs offered by fitness centres
The proportion of fitness centres offering the high intensity program ‘New Body’ decreased significantly during the Heartmoves intervention. Additionally, the proportion of centres offering the lower intensity programs of Active Over 50’s and Heartmoves increased significantly (Table 3.1) from baseline to follow-up (from 48% to 82% and from nil to 64% respectively).
3 Results
Characteristic
Baseline
(n=25)
Follow-up
(n=22)
Programs offered
Baseline
(n=25)
Follow-up
(n=22) X2** p
All clients asked at
first visit about health/
medical history.
All clients required
to complete a written
health/medical history
at first visit.
Displayed emergency
protocols for managing:
• CPR
• fainting/collapse
• chest pains
• acute shortness
of breath.
56%
40%
80%
24%
24%
28%
68%
50%
91%
55%
64%
45%
0.00
1.00
0.20
4.45
6.23
0.82
1.00
0.32
0.65
0.03*
0.01*
0.37
Health risk screening and management
Significant increases were found in the proportion
of fitness centre managers reporting risk assessment
and risk management strategies between baseline and
follow-up; in the areas of emergency protocols for
managing fainting and chest pain (Table 3.2).
Results
Table 3.2 Risk assessment and risk management strategies reported by fitness centres
* Significant difference between baseline and follow-up surveys at p<.05.
** McNemar’s Chi Squared analysis performed on matched pairs (with data at both times).
Fitness centre clients’ survey
Response rate
At baseline, the 25 fitness centres had a total of
3,066 clients. At follow-up 23 fitness centres had
a total of 2,310 clients. The response rate for the
baseline and follow-up surveys of fitness centre
clients was 60% and 72% respectively.
Characteristics of fitness centre clients
The sociodemographic characteristics of the fitness
centre clients in the baseline and follow-up surveys
are presented in Table 3.3.
Table 3.3 Sociodemographic characteristics of fitness centre clients
Mean age 35 years 34 years
Female 56% 62%
Married 57% 55%
Education – Completed secondary school or above 66% 54%
Employment – Full time, part time or self employed 67% 62%
Born in Australia 88% 87%
BMI (25 ≥ obese/overweight) 56% 54.6% 54.1%
Smoking 24% 21.8% 19.9%
Insufficient physical activity* 43% 3.0% 2.5%
Blood pressure 17% 10.6% 10.7%
Angina 16% (with a 1.2% 0.9%
Heart attack cardiovascular 1.2% 1.6%
condition)
Stroke 0.6% 0.6% 0.7%
High cholesterol 35% 8.1% 10.0%
High triglycerides No data available 1.7% 2.4%
Diabetes 2% (diagnosed) 2.3% 1.9%
Peripheral vascular disease No data available 0.5% 0.6%
Family history of heart disease No data available 26.5% 29.1%
No. of CVD risk factors:
• none 20% 23.6% 23.8%
• one 68% 42.7% 41.7%
• two (with 1 or 2 risk factors) 23.4% 23.6%
• three or more. 12% 10.0% 11.2%
CVD risk factor
AIHW
1995 data15
Baseline
(n=1831)
Follow-up
(n=1666)
* (< 800 Kcals/week)
The median length of attendance at the fitness centre
was 0.9 years at baseline and 0.4 years at follow-up.
Of those surveyed, 5% at baseline and 3% at follow-up
reported being referred by a health professional.
Self reported cardiovascular risk profile
of fitness centre clients
Table 3.4 displays the comparison between baseline
and follow-up for CVD risk factors reported by fitness
centre clients. In addition, a calculation was made of
the total number of risk factors reported for each
participant. As shown in Table 3.4, the levels of risk for
BMI and smoking are similar to those found in a 1995
population survey.15 The level of adequate physical
activity participation in the fitness centre population
is very close to 100%, which could be expected
in this sample and much higher than in the general
population. The proportion of fitness centre clients
with high blood pressure, high cholesterol levels,
and existing heart disease are less than those found
in the general population, however approximately
the same for those with diabetes.
An objective of the project was to determine
the intervention’s effectiveness in increasing the
proportion of fitness centre clients with CVD risk
factors by 5% from baseline to follow-up. However,
none of the CVD risk profile characteristics were
found to be significantly different from baseline to
follow-up (Table 3.4).
Results
Table 3.4 Self-report CVD risk profile of fitness centre clients
Fitness centre
Heartmoves participants
participants (follow-up)
Characteristics and risk factors (n=225) (n=1666) x2 p-value
Heartmoves participant survey
Response rate
The response rate for the Heartmoves participant
survey was 65% (147/225) for Heartmoves leader
distributed surveys, and 36% (74/204) for surveys
mailed by the Heartmoves leaders. The overall response
rate was 51% (221/429).
Characteristics of Heartmoves participants
A summary of the characteristics of Heartmoves
participants compared to the general fitness centre
clients measured at follow-up is provided in Table 3.5.
Heartmoves participants were significantly more likely
to be older, retired, not to be employed, not to have
completed high school and have been referred by a
GP than the general fitness centre client population.
In relation to CVD risk factors, data on the two
comparable risk factors – overweight or obesity, and
insufficient activity showed that compared to the
general fitness centre clients Heartmoves clients were
significantly more likely to be overweight or obese
(90% vs 54% p<0.001) and insufficiently active (7% vs
3%, p<0.001). Additionally 10% of participants
reported having attended cardiac rehabilitation and
14% reported attending diabetes education in the
preceding 12 months.
In the follow-up survey of general fitness centre
clients only 49 (2.9%) participants reported being
part of a Heartmoves program. However, there
were 44 programs operating in the Hunter centres at
follow-up with at least 400 participants (fitness centre
audit data). It appears likely that the random selection
of one weekday per centre on which to implement
the survey may have omitted the days on which the
Heartmoves programs were delivered. This possible
omission of Heartmoves clients from the follow-up
general fitness centre client survey, may subsequently
have influenced the finding of no significant
differences in the follow-up fitness centre
population on CVD risk factors.
The sample of general fitness centre clients
contained 49 people who reported being Heartmoves
participants. It is possible these 49 people were also
captured in the Heartmoves sample and there is no
way of identifying and therefore removing them
from the analysis. Given the large numbers in the
fitness centre sample, even if these 49 were all
removed there would be minimal effect on
the Chi Squared calculations.
Results
Table 3.5 Comparison of Heartmoves participants to fitness centre clients
Aged> 60 years 70% 6% 359.09 0.000***
Female 79% 62% 484.04 0.028***
Retired 62% 7% 275.99 0.000***
Employment – Full-time, part-time or self employed 11% 62% 75.95 0.000***
Education – Completed secondary school 33% 63% 21.12 0.000***
Married 68% 55% 3.21 0.730
Born in Australia 87% 88% 0.00 0.988
Referred by GP 24% 3% 111.66 0.000***
BMI ≥25* 90% 54% 22.77 0.000***
Insufficient physical activity** 7% 3% 11.77 0.001***
* (Obese/overweight).
** (< 800 Kcals/week).
*** Significant difference at p<.05.
3.2 Process level indicators
Quality and safety
Heartmoves leader training
The Heartmoves training manual received endorsement
from the NHFA (NSW) Cardiac Rehabilitation
Advisory Committee. Further, the training program
was successfully accredited with fitnessnsw and
awarded the maximum 15 Continuing Education
Credits (CEC) for participating fitness leaders.
Heartmoves leaders must have current registration
as a fitness leader and current CPR training.
Adherence to Heartmoves training guidelines
The first QA audit of the 22 active Heartmoves leaders
showed that 68% of leaders were ranked on average as
‘good’ and 27% ranked as ‘excellent'. The remaining
5% received an average ranking of ‘satisfactory’. As
Figure 3.1 shows, there was additional improvement
in adherence to the guidelines from the first QA
audit to the second, with 62% of leaders ranked
as ‘excellent’ on the second QA audit.
Figure 3.1 Comparison of overall scores for
fitness leaders on quality assurance audit
Adherence to pre-exercise screening procedure
Of the 400 enrolments in the Heartmoves program,
93% of participants had a completed PEAF. Of the
completed PEAFs, 80% indicated that they had a
chronic condition for which they were advised to
seek medical clearance before exercising. Of those
who indicated a chronic condition 65% signed the
‘waiver’ on the PEAF indicating that they already
had medical clearance to exercise and the remaining
35% had a written medical referral/clearance form
attached to their PEAF.
Adherence to low-moderate intensity
Figure 3.2 shows that among the Heartmoves
participants surveyed, 89% reported their Rate of
Perceived Exertion (RPE) as ≤ 5 on the modified
Borg 10 point scale (see Appendix B). A total of 79%
of the participants reported working between 3-5 on
the RPE Scale, a further 10% reported working below
3 whilst 11% reported that they were working above 5.
Figure 3.2 Rates of Perceived Exertion (RPE)
reported by Heartmoves participants
Results
0
10
20
30
40
50
60
70
80
%
Rating of quality
% of fitness leaders
Satisfactory
QA round 1
QA round 2
Good Excellent
5%
0%
68%
38%
27%
62%
0
10
20
30
40
50
%
Rates of perceived exertion
% of Heartmoves participants
(
0) Doing nothing
(
1) Very light work
(
2) Light work
(
3) Moderate work
(
4) Somewhat
hard work
(
5) Hard work
(
6) Hard work
(
7) Very hard work
(
8) Very hard
work
(
9) Very very
hard work
(
10) Couldn't possibly
do more
0%
1%
9%
46%
25%
8%
5%
1%
3%
0%
2%
Acceptability
Heartmoves training
Twenty-four fitness leaders attended the two
initial Heartmoves training workshops. Due to demand,
an additional workshop was delivered two months
later to a further 11 fitness leaders. Therefore in total,
35 fitness leaders completed the training workshop. Of
these, 63% had established a Heartmoves class within six
months of the launch (ie the training program yielded
63% ‘active’ Heartmoves leaders) and a further 34%
reported that they intended to establish a Heartmoves
class within the next 12 months.
Heartmoves participants
Satisfaction with Heartmoves
Heartmoves participants were asked to rate on a
four point Likert scale how satisfied they felt with
various aspects of the program. Response options
for ‘satisfied’ and ‘completely satisfied’ were then
aggregated and are presented in Table 3.6.
Table 3.6 Participant satisfaction with Heartmoves
Attendance and cost
Heartmoves participants reported that they averaged
about two classes or 1.4 hours of Heartmoves each
week, and walked an average of five times per week, in
addition to their Heartmoves programs. The average
cost of a Heartmoves session was $3.60, with the
majority (75%) of classes less than or equal to $5.
Almost all (95%) Heartmoves participants reported that
they thought the price was appropriate.
Fitness centre managers
The survey of Fitness Centre Managers included
questions about Managers’ perceived barriers towards
programs for special populations, and, specifically,
their awareness of, and attitudes towards, Heartmoves.
A summary of the results is contained in Table 3.7.
There were a total of 35 fitness leaders trained in
Heartmoves, some worked in centres which had not
yet adopted a Heartmoves program, but their managers
would have nevertheless been aware of the Fitness
Leader Training program and have attended the
Managers Workshop. This could explain the finding
that 100% of fitness managers thought Heartmoves
leaders were appropriately trained yet 100% did
not have a Heartmoves program operating.
The proportion of fitness managers who thought
that the lack of trained staff was a barrier to
developing programs for special populations
decreased significantly from baseline to follow-up
(p ≤ 0.05), after the Heartmoves intervention.
% reporting
satisfaction
Item (n=221)
Leader’s respect for safety 99.5
Leader’s ability to let them work at their 99.0
own speed
Leader’s understanding of their needs 98.0
Leader’s helpfulness 98.0
Leader’s music speed 96.0
Thought the name Heartmoves described 96.0
the program well
Thought that the price structure 95.0
was appropriate
Leader’s music choice 93.0
Leader’s music volume 93.0
Results
Main barrier identified to developing programs Baseline Follow-up
for specialised populations (n=25) (n=21)
Lack of trained staff 84% 48%*
Awareness/attitudes of Heartmoves
Aware of Heartmoves (n=22) NA 95%
Delivering at least one Heartmoves program (n=22) NA 64%
Agree with the following statements:
• Heartmoves has the potential to become a core program in the fitness industry (n=21) NA 67%
• Heartmoves is a good investment for the fitness industry (n=17) NA 35%
• Heartmoves has the potential to grow (n=17) NA 94%
• liability risks are too great (n=18) NA 16%
• record keeping requirements of Heartmoves are too great (n=17) NA 35%
• biggest barrier is attracting new participants when starting up new program (n=20) NA 60%
• participants might be lost when requested to get a medical clearance (n=17) NA 53%
• Heartmoves leaders adequately trained (n=17) NA 100%
• sufficient support is provided to establish Heartmoves in centre (n=17) NA 83%
Reach
Heartmoves participants
Of the 225 Heartmoves participants who responded to
the survey:
● 37% reported first finding out about Heartmoves
through family and friends
● 28% reported seeing a TV commercial for
“Active Over 50’s”
● 14% found out through allied health professionals;
● 13% found out through newspapers
● 13% reporting seeing a TV commercial for
Heartmoves (it featured in the NBN Today Extra)
● 11% found out through fitness centres
● 8% found out through mailed pamphlets
● 9% reported seeing the NSW Health ‘Tin Man’
commercial
● 6% found out through GPs.
Fitness centres
In 1999 (baseline) there were 25 fitness centres
operating in the Hunter. Seven months after the
launch of Heartmoves at the follow-up survey,
there were 23 centres still operating and the
survey of 22 consenting managers found that
14 (64%) were offering at least one Heartmoves
program. Nine months after the launch of the
Heartmoves program, the fitness centre record
audit found 18/23 (84%) were offering at least
one Heartmoves class. These centres offered a total
of 44 individual Heartmoves sessions (an average of
2.4 programs per centre). The Heartmoves programs
were offered between 9.00am and 4.00pm on
weekdays (which is known to be the quiet
period within the fitness industry). Figure 3.3
illustrates that the number of individual Heartmoves
sessions increased over the intervention period from
May 1998 to February 1999.
Results
Table 3.7 Fitness centre managers’ perception of Heartmoves programs
* McNemar’s Chi Squared analysis for matched data points at both times. X2=4.45; p ≤ 0.05.
Telephone line referral
A total of 87 calls were recorded at the Hunter
office of the Heart Foundation as a result of the
specific article on the Heartmoves program in the
Newcastle Herald (see Appendix F for a sample
of a media article). Three months later, 57% of these
callers were re-contactable and 6% had participated
in Heartmoves.
GPs and Allied Health professionals
workshop attendance
A total of 55 GPs attended the Hunter Urban
Division of General Practice workshop (there
are approximately 350 GPs in this Division) and
a further 16 GPs attended the Hunter Rural Division
of General Practice workshop (there are approximately
160 GPs in this Division). A total of 66 dietitians,
nurses and physiotherapists (from the Hunter Area
Health Service) attended the Allied Health
Professionals' Workshop.
General practitioner referrals/
medical clearance to Heartmoves
As Heartmoves programs are openly marketed,
clients can enter ‘off the street’ as well as through
a referral from a GP. The audit of Heartmoves records
in the fitness centres showed that 26% (104/400) of
the Heartmoves participants had a signed referral or
a medical clearance. An examination of the dates on
both the PEAFs and the medical referral/clearance
forms (for these 104 clients) indicated that the
GP had been proactive (instigated the referral to
Heartmoves) for 21% (22/104) of these participants and
reactive (signed the medical clearance brought
to them by a patient) for 79% (82/104) of these
participants. Additionally 41% of these 104 clients
had had a requested progress report faxed back to
the referring GP from the fitness centre.
In the survey of Heartmoves participants (n=400):
● Twenty-four percent reported that they were
referred to the classes by a health professional,
and of these:
– 42% by a GP
– 13% by a specialist
– 18% by a physiotherapist
– 11% by a nurse
– 11% by a dietitian.
● Fourteen percent reported having participated
in diabetes education in the preceding 12 months.
● Ten percent reported having participated in
cardiac rehabilitation education in the preceding
12 months.
Participants were also asked questions about
their perceptions of their GP’s attitude towards
physical activity and to Heartmoves specifically.
Fifty-one percent of participants reported that their
GP had raised the topic of physical activity in the last
Results
Months (1998-1999)
Number of fitness centres or programmes
May June July August September October November December January February
0
10
20
30
40
50
Separate Heartmoves programmes
Fitness centres
Figure 3.3 Fitness centres offering Heartmoves programs
12 months. Seventy-four percent reported that they
informed their GP about Heartmoves and of these,
78% reported their GP was supportive and
encouraging of Heartmoves.
Media coverage
In summary, local media monitoring over the
nine months of the evaluation period recorded:
● three television media coverage items/interviews
● twelve newspaper articles in the general press
● three targeted print articles in specific
newsletters (Hunter Health, Urban Division
of GP, and fitnessnsw)
● ten live Heartmoves demonstration/open days.
Retention
Heartmoves participants
A total of 400 people enrolled in the Heartmoves
program during the nine months after the public
launch. Of these, (320/400) 80% had attended their
Heartmoves program during the two weeks preceding
the audit (conducted six months after the launch)
and were therefore deemed to have been ‘retained’.
Figure 3.4 shows the steady increase in enrolments
in the Heartmoves programs over the nine months, and
the dip in enrolments over the winter months
of July and August.
Results
Figure 3.4 Number of enrolments in Heartmoves classes
May June July August September October November December January February
0
100
200
300
400
500
Insufficient physical activity is the most prevalent
population risk factor for CVD. There is also strong
evidence for the benefits of regular exercise for those
with existing chronic illnesses such as diabetes, heart
disease, asthma, arthritis, depression, and as a preventive
strategy for falls. However, there are few available
community-based exercise programs that are tailored
to the needs of these special populations, many of
whom are older and deconditioned. Fitness centres
are an appropriate setting to provide exercise programs
for special populations including those who are older
and those with stable chronic illness (provided there
is appropriate staff training and adherence to risk
assessment, risk management, medical clearance,
lower intensity and safety protocols). However,
there is still considerable opportunity to bridge the
gap between fitness centres and the health sector.
Heartmoves was an innovative intervention that
incorporated a number of strategies designed to
promote integration and overcome barriers between
the health sector and the fitness industry. Due to the
already extensive literature concerning the benefits
of physical activity participation for the individual, the
current study did not aim to measure the individual
impact of the Heartmoves program. Rather, the project
was designed to evaluate the ability of Heartmoves to
provide a sustainable and safe exercise program that
met the needs of clients and the fitness industry,
and was an attractive referral option for health
professionals.
Heartmoves attracted the target group it was
designed for, older Australians, those with risk
factors for CVD, and/or those who have stable
heart disease or diabetes. Ten percent of Heartmoves
participants reported attending a cardiac rehabilitation
program in the preceding year, and an additional
14% reported attending a diabetes education program
(indicating that 24% of the participants had existing
and recent cardiovascular disease or diabetes).
The Heartmoves intervention targeted participants
who were significantly different from the rest of
the population of fitness centre clients. Compared
to fitness centre clients, Heartmoves participants
were significantly more likely to be over 60 years,
retired, not employed, and be obese or overweight.
Heartmoves appears to be successful in attracting
a new market to fitness centres and the intervention
was shown to have changed the nature and type
of programs offered in local fitness centres. There
was a significant overall increase in the proportion
of centres offering the lower intensity programs.
There was also a significant increase in the level of
risk management of clients in relation to emergency
protocols for managing fainting spells and chest pains.
This suggests that that the introduction of Heartmoves
contributed to a refocusing in local centres towards
safety, health and older populations.
4.1 Quality, safety, acceptability,
reach and retention
Quality assurance and safety were fundamental
components of the Heartmoves program. The
Heartmoves leader training manual received
accreditation from fitnessnsw and content approval
from the NHFA, which would suggest it is a credible
resource acceptable to both the fitness industry and
relevant health professionals. Further, the quality of
the classes conducted by Heartmoves leaders were
assessed to be of a high standard. The assessed
quality of Heartmoves leaders improved during
the intervention, which may have been due to
the increasing experience of the leader and/or the
feedback provided after the first quality assessment.
Further, the majority of Heartmoves participants (93%)
had completed a PEAF, which indicates adherence
to a key safety requirement of Heartmoves.
4 Discussion
Initial demand from fitness leaders for
Heartmoves training was very encouraging,
with one-third of workshops being held due
to demand. Sixty-three percent of fitness leaders
participating in the Heartmoves training program
subsequently provided Heartmoves classes, with a
further 34% intending to do so within 12 months.
Reasons for trained Heartmoves leaders delaying
or not conducting Heartmoves classes were not
measured, however anecdotal reports from leaders
suggest that this may be related to management
decisions outside the control of individual leaders.
To ensure that appropriate supportive structures
are in place for trained Heartmoves leaders, future
evaluations of the program could consider collecting
information about ‘non-active’ Heartmoves leaders and
management. Opportunities for further targeted and
limited health sector support could be explored to
ensure establishment of the programs.
Participants in the Heartmoves program appeared
to be very satisfied with the Heartmoves leaders,
with the proportion reporting satisfaction greater than
93% in regards to leader’s understanding, helpfulness,
safety and music. Further, the majority of participants
(95%) also reported being satisfied with the price.
These results suggest that the Heartmoves program
is very acceptable to the target group. However,
alternate questions in the survey may have elicited
varied results, and non-participants were not surveyed.
Enrolments in the Heartmoves program generally
increased steadily over the intervention, with a total
of 400 people enrolling during the nine months.
Of these, 80% were retained at the time of the audit
(six months after the launch). This high retention rate
is valuable in an industry where, according to verbal
reports from fitnessnsw, the industry generally expects
a 20-30% retention rate at one year, and the survey
of general fitness centre clients at follow-up indicating
a median time at the centre of less than six months.
Heartmoves also appeared to be acceptable to fitness
centre managers. It was very encouraging that the
proportion of managers perceiving a lack of trained
staff as a barrier to developing programs for special
populations, decreased from 84% to 48% during the
intervention. This result is supported by the fact that
17/17 (100%) of the surveyed managers agreed that
Heartmoves leaders were adequately trained.
The majority of managers perceived Heartmoves
as having the potential to become a core program
in the fitness industry (67%). Further, the majority
(83%) perceived there was sufficient support to
establish Heartmoves and few (16%) thought the
liability risks were too great. Despite this apparent
support, only 35% of managers perceived Heartmoves
as a good investment for the fitness industry, yet 94%
perceived that Heartmoves had the potential to grow.
Future promotion of programs such as Heartmoves
to the fitness industry may need to emphasise the
financial viability and potential of programs for
special populations, where increased volume and
higher retention rates, combined with use of centres
at non peak times may offset the lower per person
margins. Heartmoves programs can be offered during
‘down-times’ in fitness centres (ie 10.00am-4.00pm),
which enables an attractive pricing structure.
The Heartmoves program attracted a total of
137 health professionals to the workshops. The
majority of GPs did provide a reactive referral
when prompted by their patient’s request, however,
only a small proportion of Heartmoves participants
were proactively referred to the program by a health
professional. Difficulty in engaging GPs in physical
activity promotion has been encountered in numerous
other programs. Further strategies, aside from CME
workshops and script pads, need to be evaluated in
their ability to link GPs to the fitness industry, and
physical activity promotion in general. Targeted
resource development for GPs particularly in
relation to risk management, eligibility criteria
and incorporation into Enhanced Primary Care
Planning could be considered to increase physical
activity referrals to Heartmoves.
While there is still considerable opportunity to
increase the proactive referral of participants to
Heartmoves, the program was able to strengthen
the communication between the health sector
and fitness industry. Of the 80% who indicated
any cardiovascular risk factors on the PEAF, and
who were advised to seek a medical clearance
to exercise, 35% visited their GP and received a
written referral/medical clearance to Heartmoves.
Discussion
The Heartmoves program was able to attract
local media attention, with 15 newspaper and three
television items. The most common source of finding
out about the Heartmoves program reported by
participants was through family and friends (37%),
however a wide array of sources was reported. Six
percent of those responding to one specific newspaper
article by contacting a telephone line went on to
attend a Heartmoves programs. It is therefore difficult
to establish the most effective means of promotion
for Heartmoves in the community. However, a multicomponent
strategy ensuring wide coverage is
probably the most appropriate.
4.2 CVD risk factors among
fitness centre clients
The second objective of the Heartmoves project
was to determine the intervention’s effectiveness in
increasing the proportion of fitness centre clients with
CVD risk factors by 5%.The results of the fitness centre
clients’ survey indicate that the characteristics and
cardiovascular profile of fitness centre participants at
follow-up were not significantly different from baseline.
These results, however, need to be considered in
light of potential methodological limitations. Firstly,
the time period of data collection from the launch
of the Heartmoves intervention to the follow-up
measures (six months) may have been insufficient to
enable sufficient growth of Heartmoves throughout the
industry. Secondly, the design strategy of randomly
selecting one day of the week for surveying
participants in each fitness centre may have been
too insensitive. As only 3% (n=49) of the fitness centre
clients in the follow-up sample reported that they
had participated in a Heartmoves class, the ‘random
one day/week’ nature of the data collection protocol
may not have corresponded with the days on which
Heartmoves programs were being conducted in the
fitness centres.
However, the results could also be interpreted to
suggest that few Heartmoves participants attended
the fitness centre unless it was for the specific purpose
of attending a Heartmoves class, and that Heartmoves
classes were not available on every day of the week.
Varied strategies (including increased low intensity
program choices) may be required to encourage
special populations, such as those with CVD risk
factors, to participate in wider fitness centre activities.
4.3 Low to moderate intensity
exercise classes offered by
fitness centres
The third objective of Heartmoves was to
determine the intervention’s effectiveness in
increasing the proportion of low to moderate
intensity exercise classes offered by fitness centres
in the Hunter region from baseline to follow-up.
After the Heartmoves intervention, a significantly
higher proportion of fitness centres offered lower
intensity programs. It should be noted that 64% of
centres offering Heartmoves classes is a considerable
achievement considering the competition from the
Active Over 50’s program. The Active Over 50’s
program may have been perceived from an industry
perspective as easier to implement due to less
extensive training requirements and free training
courses for leaders, fewer requirements for
record-keeping, and quality-assurance.
The number of individual Heartmoves classes
offered increased during the intervention period,
whereas the number of participating Centres peaked
during the middle of the intervention and then
dropped slightly. This drop (two centres) however,
resulted from the Quality Assurance Audit that
revealed that the Heartmoves brand had been
applied to existing ‘gentle’ exercise classes, without
appropriate change to the structure and intensity
levels of the programs. The number of enrolments
in the Heartmoves program also increased during
the intervention. This would suggest that strategies
to promote the Heartmoves program should aim
to increase not only the number of participating
centres, but also the number of individual classes
offered by each centre.
Discussion
During the Heartmoves intervention, a concurrent
study of the physical activity behaviour of patients
in Hunter cardiac rehabilitation programs was
conducted. Phase II outpatient cardiac rehabilitation
(OCR) usually occurs within four weeks of discharge
from hospital after a cardiac event. It is a five to six
week program usually two sessions per week, which
includes: supervised exercise program, additional
education about lifestyle change and counselling
components. The study of these phase II patients
provided data about the physical activity participation
before and after hospitalisation, and specifically,
participation in the Heartmoves program.
5.1 Objectives
The objectives of the concurrent study of phase II cardiac rehabilitation patients were to determine:
1 The retrospectively self-reported level of physical activity participation prior to hospitalisation.
2 Changes in the level, and type of, physical activity participation (including Heartmoves) at three and
nine months post-discharge.
5.2 Methods
Study design
The study involved a retrospective self-report survey, and two telephone interviews of cardiac rehabilitation patients to determine changes in physical activity participation.
Data collection
Patients from all cardiac rehabilitation programs
in the Hunter (John Hunter Hospital and Lake
Macquarie Private Hospital) were recruited to the
study over a nine month period from March 1998
to January 1999. Recruitment occurred during
the second week of the patient’s program.
Lists of class participants were provided by
cardiac rehabilitation staff. Packs containing
an information letter, a de-identified consent form
with a survey and an envelope were then forwarded
to cardiac rehabilitation staff for distribution. Cardiac
rehabilitation staff were responsible for giving a brief
description of the research and ensuring that each
patient in the class received their envelope containing
the study pack. This strategy ensured that all patients
in the rehabilitation program had an opportunity to
participate in the study.
Consenting patients returned their completed
surveys to a labelled box in the room where the
rehabilitation program was conducted with patients
indicating a difficulty with survey completion being
offered a telephone interview. Patients were informed
in the letter that in addition to the survey,
participation involved two telephone interviews
in three and nine months time.
Survey
The questionnaire in the survey of cardiac
rehabilitation patients asked the same core
questions as the fitness centre clients’ survey,
except that self reported participation in physical
activity was asked retrospectively for an average week
prior to hospitalisation. Due to all the patients being
in a rehabilitation program where they were engaged
in supervised exercise twice a week, it was considered
inappropriate to ask about the last week’s participation
in physical activity. Patients were also asked about their
perceived interest and barriers to participating in
ongoing post-rehabilitation community based
exercise programs.
During the telephone interview conducted three
months after the initial survey (prior to the launch
of Heartmoves) the participants were asked about:
● participation in physical activity in the last week
● knowledge of the new moderate physical
activity message
● current smoking status
● whether they had visited their GP since discharge
● health professional advice relating to secondary
prevention of CVD
● perceived barriers to ongoing participation in
physical activity.
5 Concurrent study 1 –
Cardiac rehabilitation cohort
Table 5.1 Sociodemographic characteristics of cardiac rehabilitation patients (n=237)
(n=237) number %
Average age 63.6 years (mean)
Female 52 (22%)
Married 190 (80%)
Education – Secondary school, HSC, TAFE, CAE 70 (32%)
Employment – Full time, part time or self employed 59 (26%)
Nationality – Australian 172 (85%)
During the telephone interview conducted nine
months after the initial survey (and after the launch
of Heartmoves) participants were asked the same
questions as in the previous interview with additional
questions about knowledge, attitudes and participation
in Heartmoves. Participants were also asked about any
re-admissions to hospital for further heart problems.
Analysis
Frequencies were calculated for descriptive data
using Stata statistical package – Version 5. Refer to
Appendix E for calculation of BMI and ‘adequate
physical activity’.
5.3 Results
Response rate and loss to follow-up
Of the 446 patients attending OCR during the
period, 69% were deemed eligible (ie mentally,
physically and emotionally capable of providing
informed consent) for the study by usual care
cardiac rehabilitation staff. Of these eligible
patients participating in the second week of a
cardiac rehabilitation program, 77% consented
to participate in the study. At the three month
telephone follow-up 199 were contacted and
at nine months follow-up 191 were contacted.
Overall loss to follow-up at nine months
was 19%.
Sociodemographic characteristics
The characteristics of the cardiac rehabilitation
patients surveyed are described in Table 5.1.
Self reported cardiovascular risk profile
of cardiac rehabilitation patients
The results of the initial retrospective survey show
high rates of cardiovascular disease risk factors prior
to the patient’s hospitalisation. In the subsequent
telephone interviews, only modifiable risk factors
were surveyed. Although cholesterol and blood
pressure are modifiable, the question was ‘had they
ever been told by a health professional that they
had high cholesterol or blood pressure’; not
what the actual level was.
Table 5.2 shows a reduction in the proportion
of participants reporting the cardiovascular risk
factors of obesity/overweight and smoking from
pre-hospitalisation to three months follow-up.
The proportion reporting the risk factor of obesity/
overweight was further reduced at nine months
follow-up. However, there was no further reduction
in the proportion reporting smoking at the nine
month follow-up. The proportion of patients
reporting insufficient physical activity increased
from pre-hospitalisation to follow-up.
Cardia rehabilitation cohort
CVD risk factor
Pre hospitalisation
baseline %
(n=237)
Three months
follow-up %
(n=199)
Nine months
follow-up %
(n=191)
Continuation of exercise
after rehabilitation
The majority of cardiac rehabilitation patients (78%)
indicated being interested or very interested in joining
a program such as Heartmoves in the initial survey,
while 63% reported being interested in joining a
walking group.
Heartmoves attendance and awareness
The Heartmoves program was launched to the
public after the three months follow-up telephone
interview of the cardiac rehabilitation patients.
During the nine month interview, 40% of participants
reported awareness of Heartmoves. Of these, 29% were
advised by a health professional and 15% found out
from a newspaper.
In terms of attendance at a Heartmoves class, at
nine months post cardiac rehabilitation 7% of patients
reported having attended a class. Of those who had
not attended, 39% reported that they intended to go
to Heartmoves in the next six months. In terms of
strategies that might encourage attendance at
a fitness centre based exercise program:
● Sixty-four percent thought that a prescription
from a cardiologist, GP or Rehabilitation
Coordinator outlining the type and amount
of exercise would be useful.
● Sixty-four percent thought that a Hunter
telephone number providing details of where
they could go would be useful.
● Fifty-four percent thought that being able to
continue with the same group of people as in
the cardiac rehabilitation class would be useful.
Barriers to exercise participation
post-rehabilitation
Table 5.3 shows that the barriers described
as reasons for not continuing to participate in
exercise after cardiac rehabilitation, changed from
baseline to three and nine months. At baseline,
patients were asked whether each of the reasons
listed might be a problem for them to continue
physical activity after their cardiac rehabilitation
program. At three and nine months they were
asked which reasons might be a problem for
continuing with physical activity.
Cardia rehabilitation cohort
Table 5.2 Self reported cardiovascular risk profile of cardiac rehabilitation patients
BMI ≥ 25 (obese/overweight) 79 71 69
Smoking 20 10 10
Insufficient physical activity (< 800 Kcals/week) 11 20 17
Blood pressure 54 Not asked Not asked
– medication for BP 50
Angina 36 Not asked Not asked
Heart attack 19 Not asked Not asked
Stroke 12 Not asked Not asked
High cholesterol 52 Not asked Not asked
– medication for cholesterol 36
High triglycerides 24 Not asked Not asked
Diabetes 20 Not asked Not asked
– medication for diabetes 15
Peripheral vascular disease 8 Not asked Not asked
Family history 54 Not asked Not asked
Baseline three months nine months
Reasons for not exercising % % %
Table 5.3 Cardiac rehabilitation patients’ reasons for not exercising
Cardia rehabilitation cohort
Cost of attending fitness centre classes 41 20 15
Physically limiting condition (eg back injury) 37 36 38
Don’t know where to find an exercise program 31 13 4
Did not think exercise is important for recovery 13 3 0
Unable to take time off work 12 5 7
Transport difficulties 10 6 3
Not being well enough to exercise 11 16 11
Thought exercise might be harmful 4 1 3
Advised by medical person not to exercise 3 0 0
Patients’ report of receiving secondary prevention
The proportions of patients reporting secondary prevention care delivered by GPs (95% reported visiting their
GP by the three month interview), cardiac rehabilitation nurses and cardiologists at three and nine months after
cardiac rehabilitation are shown in Figures 5.1, 5.2 and 5.3 respectively. The figures also describe the advice
reported being given by the GP, cardiac rehabilitation nurse or cardiologist.
Figure 5.1 Patient reported advice from general practitioner for secondary prevention
%
Medication for diabetes
Medication for high cholesterol
Medication for high blood pressure
Advised to follow a special diet
Advised NOT to take aspirin
Advised to take aspirin
Advised to walk
Advised to exercise
Advised to use Quitline
Advice about NRT
0 10 20 30 40 50 60
9 months (n=191)
3 months (n=199)
13%
9%
53%
37%
52%
39%
30%
32%
5%
7%
48%
37%
1%
6%
7%
8%
4%
2%
26%
9%
Figure 5.2 Patient reported advice from cardiac rehabilitation nurse for secondary prevention
Cardia rehabilitation cohort
%
Medication for diabetes
Medication for high cholesterol
Medication for high blood pressure
Advised to follow a special diet
Advised NOT to take aspirin
Advised to take aspirin
Advised to walk
Advised to exercise
Advised to use Quitline
Advice about NRT
0%
0%
0%
4%
1%
2%
32%
43%
1%
2%
8%
13%
18%
14%
19%
0%
0%
0%
2%
0%
0 10 20 30 40 50
9 months (n=191)
3 months (n=199)
Figure 5.3 Patient reported advice from cardiologist for secondary prevention
0 10 20 30 40 50 60 70 80 %
Medication for diabetes
Medication for high cholesterol
Medication for high blood pressure
Advised to follow a special diet
Advised NOT to take aspirin
Advised to take aspirin
Advised to walk
Advised to exercise
Advised to use Quitline
Advice about NRT
1%
1%
63%
49%
48%
34%
29%
33%
5%
6%
65%
3%
5%
12%
15%
0%
0%
18%
2%
80%
9 months (n=191)
3 months (n=199)
Cardiologists and GPs gave more medication
advice than lifestyle advice to the cardiac
rehabilitation patients with less than 20%
of patients receiving advice from their GP or
cardiologist about exercise or walking. This is of
concern given that 80% of these patients were
overweight/obese, half had elevated BP and
cholesterol and 20% were diabetic, all conditions
for which exercise therapy is strongly recommended.
Patients reported more advice from GPs in relation
to nicotine replacement therapy, blood pressure and
diabetes; more advice from cardiologists in relation
to cholesterol and aspirin; and more advice from
cardiac rehabilitation nurses on lifestyle factors
such as diet and exercise.
5.4 Discussion
As was expected, many of the surveyed patients
reported cardiovascular risk factors. However, only
11% reported being inadequately active prior to
hospitalisation. Unlike the other CVD risk factors
of smoking and obesity/overweight, which decreased
at the three and nine month follow-ups, inadequate
physical activity as a risk factor, increased at three
months and at nine months. These rates are
considerably lower than the state average
for inadequate levels of physical activity
(approximately 50%).
This lower reported rate of physical inactivity among
cardiac patients may be due to misreporting, or due
to problems with the measurement instrument among
this population. For example, it is possible that the
high rates of reported physical activity participation
may be an artefact of the measurement instrument
and the way the questions are interpreted by this
specific population. The description of ‘vigorous’
activity on the standard physical activity questionnaire
– ‘any activity which makes you breathe harder or puff
and pant’ may not be appropriate for individuals with
recent heart disease, as the symptoms of CVD namely,
shortness of breath, sweating, puffing on any exertion
may be confounding the measurement
of physical activity among this population (where
any activity may cause such a response, and therefore
have been classified as vigorous or indeed moderate).
Further research is needed to clarify the reliability
of physical activity measures for this population.
However, it is evident that there is a need for
physical activity programs in this population to
encourage continued involvement post-rehabilitation.
The majority of patients (78%) were interested
in Heartmoves or joining a walking group (63%).
Despite this initial interest however, few (7%)
actually participated in Heartmoves. The importance of
the involvement of a health professional was
emphasised with 64% reporting that a prescription
would encourage them to attend a fitness centre
based exercise program, yet only 8%, 15% and 19%
were advised to exercise by cardiologist, GP and
Cardiac Rehabilitation Coordinator respectively.
It is encouraging that the perceived barriers
to exercise participation decreased over the time
of the study. The most consistent barrier was
a physically limiting condition (eg back injury).
The overcoming of such a barrier would require
even greater involvement from health professionals
in the referral of patients to appropriate exercise
programs.
The results of this study demonstrate and reinforce the
important role of health professionals in encouraging
patients to exercise. While there appears to be
substantial interest in exercise participation by the
patients, only small proportions of patients report
being encouraged by health professionals to exercise.
Patients themselves have identified that referrals
from health professionals would encourage them to
participate, and such referrals may assist in overcoming
the perceived barriers to participation held by this
special population group. It will be important
to identify and address the barriers to exercise
prescription among the cardio vascular disease
health professionals.
Cardia rehabilitation cohort
Walking is an excellent moderate physical activity,
can be undertaken by most people and is inexpensive.
It therefore seems appropriate for organisations to
support walking programs that aim to promote
increased physical activity through supported
structured walking programs (usually providing
a leader, a regular route, and public liability
cover for the leader).
During the Heartmoves intervention, a number
of walking groups were operating in the Hunter.
These included: the Department of Sport and
Recreation (DSR) Walking for Pleasure program,
the NHF Just Walk It program, and the AMP Mall
Walking program. A study of these walking groups
by the NHF was concurrently conducted during
the evaluation of the Heartmoves program.
6.1 Objectives
The objectives of the study were to describe:
● the sociodemographic characteristics, self
reported health status, physical activity profile,
CVD risk status, and participation frequency of
walking program participants in the Hunter
● the number and type of community based
walking programs being offered in the Hunter
● changes in the proportion of individuals with a
CVD profile participating in walking programs
from baseline to follow-up.
6.2 Methods
Study design
At baseline, a self-complete survey of walking
group participants was conducted and the follow-up
survey one year later. Walking group leaders were
also interviewed about the number of members
in their program.
Data collection
Only participants from the Walking for Pleasure
program and the Mall Walking program were
recruited in the baseline survey, as there were
no Just Walk It groups operating in the Hunter
at that time.
At baseline, Walking for Pleasure groups were identified
from a Department of Sport and Recreation database
and telephone contact made with leaders to verify
the group was still operational. The information,
consent letter and questionnaire were mailed to all
registered participants by the Department of Sport
and Recreation on behalf of the NHF for privacy
reasons. To recruit survey participants from the
Mall Walking group, a project officer visited the
group on four consecutive days.
Walking group leaders were asked to complete an
information sheet regarding the number of regular
walkers in the program. To calculate the total
number of walkers in the group, the denominator
was calculated as the total number of walkers
registered with the program (each walker
completed a membership card).
To encourage participation in the survey, walkers
were offered entry into a prize draw for a NHFA
pack containing a cookbook, t-shirt, cap, and
health booklets.
In the follow-up survey, questionnaires were
sent to all walkers registered with the Just Walk It
program in addition to Walking For Pleasure program
participants, and four visits were again made to the
Mall Walking group.
Measurement
Questionnaire
The self-complete questionnaire was essentially the
same as the fitness centre participants’ survey except
questions were included about the length of time as
a walking program member and the mechanism for
hearing about the program. The follow-up survey
conducted 12 months later was identical.
6 Concurrent study 2 – Walking group
Baseline Follow up
(n=144) (n=102)
response response
rate rate
Walking for Pleasure 17.0% 23%
Coalfields Club
Walking for Pleasure 28.0% 50%
East Lakes Club
Walking for Pleasure 16.0% 20%
Hamilton Happy Walkers
Walking for Pleasure 41.0% Ceased
Lake Munmorah
Walking for Pleasure 18.0% Ceased
San Remo
Walking for Pleasure 50.0% 72%
Newcastle Happy Wanderers
Walking for Pleasure 77.5% 63%
Port Stephens Club
Walking for Pleasure 36% Ceased
Berkeley Vale
Mall Walking 37% 38%
Walking for Pleasure N/A 58%
Warner’s Bay
Just Walk It N/A 21%
Total 36% 38%
Table 6.1 Walking group survey response rates
Analysis
Frequencies were calculated for descriptive data
using Stata statistical package – Version 5. Differences
between baseline and follow-up proportions of
participants with a CVD risk profile in the walking
groups were reported. Refer to Appendix E for
calculations of BMI and ‘adequate physical activity’.
6.3 Results
Response rate
Eleven Walking for Pleasure groups were identified
by DSR and one Mall Walking group was identified
by AMP. Leaders were contacted to verify operational
status and to provide membership numbers, yielding
only eight Walking for Pleasure groups with an
estimated 301 participants, and one Mall Walking
group with an estimated 100 members at baseline.
A total of 401 questionnaires were distributed and
yielded a response rate of 36%. At follow-up,
12 months later, the Just Walk It program had
commenced, with a membership of 80; the Mall
Walking still operated with a reported membership
of 60; three Walking for Pleasure groups had ceased
operating and one new one had started, with a
total membership of 126 walkers. A total of 266
questionnaires were sent to leaders at follow-up,
and 38% were returned. The breakdown of walking
groups’ response rates is reported in Table 6.1.
Walking group
Sociodemographic characteristics
of walking group sample
Among the sample of walkers who responded to the
survey, 25% of the sample were aged over 60 years;
69% were retired at baseline and 63% retired at
follow up.
Baseline Follow up
CVD Risk factor (n=144) (n=102)
BMI ≥ 25 (obese/overweight) 54 56
Smoking 1 5
Insufficient physical activity 1 4
(< 800 Kcals/week)
Blood pressure 31 30
– medication for BP 27 30
Angina 11 12
Heart attack 8 9
Stroke 5 1
High cholesterol 40 22
– medication for cholesterol 39 22
High triglycerides 15 7
Diabetes 6 4
– medication for diabetes 4 3
Peripheral vascular disease 8 3
Table 6.2 Sociodemographic characteristics of the walking sample
Baseline (n=144) Follow up (n=102)
Number % Number %
Walking group
Average age 62.8 years (mean) 64 years (mean)
Female 107 75% 101 69%
Married 89 62% 72 71%
Education – Secondary school, HSC, TAFE, CAE 38 27% 30 33%
Employment – Full time, part time or self employed 14 10% 12 12%
Nationality – Australian 90 86% 65 85%
Self reported cardiovascular risk profile
of walking sample
Walkers were asked to report on their cardiovascular
risks, which are reported in Table 6.3.
Table 6.3 Self reported cardiovascular risk profile
of walking sample
6.4 Discussion
This survey of walking group participants from
the Walking for Pleasure, Just Walk It, and AMP Mall
Walking programs indicated a decrease in participation
over the study period. The initial number participating
in these programs (401) decreased by 35% to 266 at
follow-up.
Based on their sociodemographic characteristics,
walkers were similar to the Heartmoves participants.
There were two cardiovascular risk factors for which
there was comparable data (BMI and physical
inactivity), however, walkers were less likely to be
overweight or obese (56% compared to 90%) and
less likely to be inadequately active (4% compared
to 7%) than Heartmoves participants.
Few (2%) walking program participants reported
being referred by their doctor. It is evident that there
is ample opportunity to increase the involvement
of health professionals in the provision of exercise
advice and referral.
While walking programs are inexpensive, and
suitable to many older adults, there is substantial
organisational support required in recruiting
participants and sustaining the walking programs.
Further, walking programs require the continued
involvement of community volunteers (as program
leaders). Health professional referral and support of
walking programs may facilitate increased participation
in such programs, and thereby sustain organisational
commitment to the coordination and promotion of
walking programs. However, it is recommended that
managing organisations monitor the sustainability
and retention rates of their walking programs.
Overall numbers participating in walking
groups reduced in the year of the study, and
overall proportions reporting each of the risk
factors did not vary greatly over the 12 months.
Walking group characteristics
At baseline, 87% reported being members of their
group for more than one year, whereas at follow-up
only 61% reported being members for more than
one year. At baseline, 63% reported hearing about
their group from a friend, and 2% reported being
referred by their doctor.

7 Summary and recommendations
7.1 Summary
The benefits of physical activity for health and well-being are well recognised, and there are clear recommendations for moderate activity from numerous health organisations. Reducing hypertension, hyperlipidaemia and obesity/overweight and preventing falls are just some of the health benefits of physical activity, which are particularly relevant to special population groups, such as those with CVD or its associated risk factors.
These special population groups may be apprehensive about exercise participation, and especially within the fitness industry. However, the fitness industry is an appropriate setting for the provision of programs for special population groups, due to fitness centres’ accessibility, utilities, and fitness leader training and accreditation and the professional indemnity and public liability coverage afforded through registration.
There is a recognised gap however, between the health sector and fitness industry as well as poor rates of exercise referral by health professionals and a dearth of safe low intensity programs within the fitness industry suitable for older people and safe for those with stable chronic illness.
This project developed and evaluated a community intervention incorporating a new exercise program, Heartmoves, which was designed to be open to all and safe for those with stable CVD or diabetes.
The intervention also incorporated a number of supporting strategies designed to promote integration and overcome barriers between the health sector and the exercise industry. The project evaluated the Heartmoves intervention in relation to:
● sustainability within the fitness industry
● safety of delivery
● acceptability to clients (retention), the fitness industry (reach) and the health sector (referrals)
● its ability to increase the proportion of clients with risk factors for CVD exercising within the fitness industry.
In summary the outcomes were positive, with the training of Heartmoves fitness leaders being endorsed and accredited, and attracting significant interest among fitness leaders. Heartmoves programs attracted the target group they were designed for, older Australians and those who have or are at risk of developing heart disease or diabetes. The programs showed excellent reach across the fitness industry, steady growth in numbers, high retention rates, acceptable cost structure, public acceptability and use of centres in the down-time suggesting a sustainable product with a strong potential for the future. This is reflected in the attitudes of the fitness managers. The introduction of Heartmoves into the fitness industry produced positive change in the industry increasing routine health screening prior to exercising, record keeping, progress reporting back to referring GPs and use of safety protocols. The Quality Assurance Audit demonstrated that fitness leaders were able to deliver safe programs which adhered to their training guidelines, provided a professional environment for individuals to exercise at a low to moderate intensity in relatively small classes in over 24 locations (18 within fitness centres and six in community locations) within one Area Health Service. The adherence by leaders to the low to moderate intensity of the Heartmoves programs was the most crucial aspect for ensuring a safe, non-medically
supervised community based program. This component delivers confidence to referring medical practitioners and allied health professionals particularly in relation to patients with CVD and diabetes. A potential limitation of the study could be that the Quality Assurance Audits were conducted by the cardiac rehabilitation coordinator from the training team. As such, there is a potential for either over or under reporting on adherence
to the guidelines. Future Quality Assurance Audits on the programs should be conducted by an independent assessor.
The evaluation of the Heartmoves intervention did not find any significant increase in the proportion of clients with CVD exercising in the fitness industry in the Hunter. This may however have been affected by a study limitation, namely the random selection of the data collection day for the follow-up client survey in each fitness centre. As Heartmoves classes are not offered on all days of the week in each centre, the methodology used resulted in only 3% of the Heartmoves population being recruited within the general fitness centre survey population. Secondly, the method of recruitment for the Heartmoves participant survey (using leaders to distribute the surveys) was less than optimum for consent rates.
The results of this study suggest that Heartmoves has the potential to become a core program within the fitness industry and provide a valuable community exercise resource for the health sector (with the benefits of industry backing, professional indemnity and public liability coverage). The high retention rates are also valued by health professional organisations
campaigning to encourage people to maintain their physical activity in the long term. Heartmoves and the supporting strategies, were able to strengthen the communication between the health sector and fitness industry.
The study has highlighted a number of issues in the promotion and provision of physical activity
opportunities for older adults, and particularly those that attempt to integrate clients with stable chronic illnesses such as CVD or diabetes into community based group exercise programs.
Firstly, there is still ample opportunity to increase the involvement of health professionals in referring and encouraging participation in physical activity by special population groups. While Heartmoves did facilitate communication between participants and
their health professional about the exercise program, and GPs were engaged in medical clearance/referral for 26% of Heartmoves participants surveyed, the vast
majority of these were reactive medical clearance requests, rather than pro-active referrals. Similar to the walking programs, Heartmoves was unable to stimulate pro-active referral. The cardiac cohort study demonstrated that even general advice to exercise from health professionals is not common.
Secondly, there is significant interest in physical activity programs such as Heartmoves amongst patients attending cardiac rehabilitation. However, few cardiac rehabilitation patients actually participated in either Heartmoves or one of the concurrent walking programs. Clearly, there is need to build on the transition to Heartmoves and capitalise upon the intention to exercise in Heartmoves expressed by this special population group and overcome the barriers to actually beginning Heartmoves.  There are numerous opportunities to further promote and increase participation in physical activity programs such as Heartmoves. Strategies, other than workshops and script pads, to engage health professionals in physical activity promotion are required (including specific Heartmoves resources for determining eligibility of clients and for referring patients proactively). There is opportunity now for significant support from health groups involved in the delivery of cardiac rehabilitation, diabetes education, chronic disease management, from Divisions of GP as well as from general practitioners and practice nurses to utilise the existing resource of Heartmoves. Further, the value of social marketing should not be overlooked, as friends or family and the media inform many participants about physical activity programs.
7.2 Recommendations
From the Heartmoves project and concurrent studies, a number of recommendations to inform future physical activity projects targeting older adults, particularly those with CVD or its associated risk factors, can be made:
1 Fitness centres are an appropriate setting for the provision of specialist physical activity programs, however, marketing strategies should engage the fitness centre managers and focus on financial viability and potential of such programs (retention rates, size of the target market).
2 Registered fitness leaders provided with additional specialised Heartmoves training can deliver safe, appropriate, community based exercise programs of high quality and adhere to the risk assessment and risk management guidelines appropriate for older clients, particularly those with CVD and diabetes.
3 Further investigation is required into strategies to engage health professionals in physical activity promotion, including referral to physical activity programs, beyond existing strategies such as workshops and script pads.
4 Social marketing strategies to promote specialist physical activity programs should be multi-component to ensure wide coverage.
5 Continued monitoring of programs, particularly monitoring referral sources and collecting data about participants’ reasons for ‘dropping-out’ would provide valuable information to inform future programs.
6 Heartmoves has been shown to be a safe, viable, attractive, affordable, community based exercise option and a program to which health professionals can confidently refer older clients, particularly those with or at risk of CVD and diabetes.
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