Last week I attended the first International Conference for Social Prescribing at Salford University. Discussions there recognised the fundamental challenge of creating interest and motivation for people to start participating in physical activity and maintaining their participation in the long term. This difficulty is encapsulated in the idea of ‘behaviour change’, which has been a key phrase for many community health and exercise programmes over the past few years, alongside having a clear ‘theory of change’ that articulates the outcomes we expect a programme will create, and how. This is not an easy thing for organisations of any size to achieve.
While potential methods of driving behaviour change were discussed, there seemed to be an overwhelming emphasis on measuring it. This leads me to make a suggestion: we need to stop focusing so much on the outcomes. If people are being physically active and participating in socially inclusive and meaningful activities, there will be wellbeing and clinical benefits. Yes, this will vary from programme to programme and activity to activity but fundamentally, positive things tend to happen. What we haven’t cracked yet is the right design, implementation, promotion and sustainability of these programmes.
The shift needs to be away from the singular and reductionist question of ‘Do physical activity programmes work?’ to a more pragmatic and realist question: ‘What works, for whom, and under what circumstances?’
Initially this sounds like the outcome evaluation of exercise has become even more complex… and it has. Exercise is a complex intervention; it’s difficult to standardise. 11 people participating in the same game of football for 90 minutes will each have a unique experience and outcomes. The right outcome measurement tool for community services may capture a proportion of the true outcomes, but it will miss incredible, unique benefits. Like a person who was reunited with their best friend from 60 years ago during a bowls match. Or another with long-term mental health problems whose participation in an art class catalysed a shift from being in crisis to leading change in mental health care and becoming medication free.
Community health and wellbeing programmes work. It will always depend on individual circumstances, but fundamentally, they work. What we haven’t figured out is how to make them work operationally. The rhetoric behind ‘demonstrating the outcomes’ is often to reach the holy grail of a community health and wellbeing programme: being commissioned and paid for by the public purse. But the reality is that this isn’t being achieved on anywhere near a grand scale – even the largest charities with considerable budget and skills for evaluation struggle to achieve this.
I’m not suggesting we ignore outcomes. I’m proposing that we channel more focus on gaining knowledge to create a system of greater outputs (numbers of people who access and benefit from the activity, product or service). The people taking part in Oomph! sessions around the country are not doing it because they heard in a research study that exercise improves quality of life, and that strength and balance programmes reduce the risk of falls. They are taking part because it is fun. They will have outcomes – physical, mental, social, emotional, economic, personal. But to me the most powerful achievement is that people WANT to take part. They don’t drag themselves to sessions because they’ve been prescribed it as part of a 12-week programme; they turn up early, they have a brilliant time, and they look forward to the next one.
That’s behaviour change. That’s a system change creating a service that operationally works following a theory of change.
The question I ask myself daily is how can we make the services and offerings in the community as appealing as a cold pint and a burger? How do we make them so fun, rewarding and even naughty that people can’t help but take part? No GP practice or hospital was prescribing Pokémon Go, but 5.3 million people in the UK played it, with the average ‘Pokémon Trainer’ walking an extra 2,000 steps every time they played the same. Importantly, people with the lowest levels of activity walked an additional 3,000 more steps a day after playing the game.
We need to shift our focus from measuring outcomes to fostering engagement. By harnessing the same strategies that international conglomerates use to make that cold beer and burger so appealing and addictive, we can make radical behaviour change desirable. The activities that make up our health and wellbeing services will cease to be called health and wellbeing services: it will just be, ‘you’ve got to come and try this!’.
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