An extract from the PCT Health Equity Report (2007- 2009)

On SF36 analyses of Healthy Moves and Self-management courses

Some findings from the BMed Sci student Project May 2009 titled
“AN EVALUATION OF THE IMPACT OF SELF MANAGEMENT COURSES WITHIN TOWER HAMLETS; A)
PATIENT/PARTICIPANT ASSESSMENT OF COURSES AND B) PRIMARY CARE CLINICIAN’S KNOWLEDGE OF
COURSES”

Funded by the Health Foundation

Based in the Clinical Effectiveness Group,
Working in partnership with Social action for Health and Tower Hamlets PCT
 • Assessing primary care staff understanding of self management groups

In January 2009 a survey of all GP practices was undertaken to explore understanding

and current referral levels to both generic SMGs such as the expert patient programme
and to disease specific courses such as HAMLET and pulmonary rehabilitation.
There was 100/265 (37.7%) response rate, with a response from 31/38 practices.
88% of responders knew about the EPP, and 76 % were aware of the EPP courses
based within Tower Hamlets. However 52% were not aware of the referral process to
the generic self management courses.

Referrals to expert patient programmes

This illustrates the low level of referrals to the expert patient programme initiated by
primary care teams

Feedback and views on self management courses

In general respondents gained more feedback about attendance at disease specific
courses, and the perception of these courses was more positive than for the generic
EPP.
Response Generic Expert Patient Disease Specific Expert
Programmes % Patient Programmes %
Received Yes 35 56
course No 63 38
feedback
Nature of Positive 12 35
feedback Negative 6 4
 Mixed 19 18

Social marketing and the referral process to SMGs

The following comments are taken from the free text section of the questionnaire,
looking at the theme of ‘course referral and proceedures’. They illustrate the current
difficulties primary care teams have in understanding the role of the generic courses in
the chronic disease management pathway.

2 Course procedure
2.1 Advertising 2.2 Referral 2.3 Follow up 2.4 Education
V12: Programs are M1: Difficult to know R8: Refresher HH12: I would like to
not well marketed who attends as there are courses are attend a session to see for
no referral forms? required myself how to motivate
patients
R4: I find it difficult V3: Should be one point M1: Monitoring B3: Patients should be
to refer patients to of referral for exercise system needed receiving education every
EPP due to the lack courses time they visit the
of details of where surgery
and when they are.
N3: Need course N3: Need a referral V12: Courses 00: More group
timetables available process are never education sessions are
followed up needed for staff
II1: Must be widely V6: I feel that referring F5: Need poor training
marketed directly at patients to EPP in some refresher opportunities
patients ways feels like rejection courses
to the patient. I would
prefer if the patient was
directly contacted by the
organisation.
V4: We need visual V4: We need to encourage
promotional material self referrals
and take home
photocopies and
leaflets
V4: Patient has left J2: Promote self referrals
leaflets about courses
in the practice
J2: More promotional Y1: enable a standardised
material around the referral process where
community to help attendance can be
advertise courses to monitored
patients
O1: More advertising
material is required
for patients and
doctors
00: no code

Improved take up of these generic EPP courses will depend on a strong PCT wide focus
on publicity, self referral mechanisms and a single point of entry for health professional
referral.

These comments apply less to the disease specific SMGs, which fall more within the
traditional medical model and show more evidence of becoming attached to the disease
pathway.

(Further details of the survey method and full results available on request from the
project team)

Analysis of the ‘Healthy Moves’ SMG run by Social Action for Health

The Healthy moves course was developed by SAfH as a hybrid self

management/exercise course containing self efficacy elements of the EPP programme,
but including more directive sessions on diet and activity, with sessions on common
chronic diseases such as diabetes and heart disease. There is an emphasis on doing
physical activity during the sessions.

The analysis is based on 20 courses, which ran during January to March 2009.

• 66% of the participants attending the courses were female

• 93% of course participants were Bangladeshi

• Over 85% of course attendees had diabetes

• 75% of participants were directly invited to attend the course by SAfH, 13% were
recruited by their doctors.
Healthy Moves course content

Week Healthy Moves course topic

Week 1 Introduction to Healthy Moves and meeting the group
Know about the broad aspect of health
Understand the Healthy Moves approach and experienced body listening/basic
awareness
Week 2 Learn about the skeletal and muscular system
Map through movement and be aware of various organs
Activity plan
Week 3 Understand the importance of physical activity
Developing ideas of how to be physically active
Problem solving
Activity plan
Week 4 Plan lifestyle changes
Problem solving
Gain knowledge of five food groups, design eat well plate, understand food labels
Considering your own diet
Feedback on activity plans
Week 5 Understanding the digestive system
Awareness of cultural influences on diet and the consequences
Improving diet without changing cultural food
Week 6 Understand the anatomy of the heart, relationship of coronary heart disease and diet
and physical exercise
Understand the relationship between diabetes and physical activity
Importance of physical activity
Week 7 Explore what stress is and how it effects health
Relaxation through breathing techniques and body awareness
Physiological impact of stress on the body
Or
Session related to diabetes
Week 8 Review and feedback
Taking learning forward to everyday life, making a pledge and chart plan

The course analysis is based on data from the SF-36, which is a standard instrument
used to assess quality of life and changes in scores following interventions. The SF-36
has 8 scales, which are combined to make up two summary measures, physical health
and mental health. Each scale has between 2-10 items, scales are scored 0-100;
individuals with higher scores relate to greater levels of health and function

SF 36 Scale Description Summary

Item no measure
3a,b,c,d, Physical function
Measurement of physical Physical health
e,f,g,h,i,j performance from vigorous Overall measure of
activities to bathing and dressing physical limitations
4a,b,c,d Role physical Measurement of any difficulties in self care, social
with daily activities or health and role activities,
problems which restrict working accounting for
capacity pain, disability and
7,8 Bodily pain Measurement of pain magnitude energy levels
and interference
1,11a,b,c General health Measurement of individual’s
,d perceived health status from poor
to excellent
9a,e,g,i Vitality Measurement of energy levels Mental health
6,10 Social functioning Measurement of health status Overall measure of
effects on normal social activities mental wellbeing
5a,b,c Role emotional Measures effect of emotional encompassing
problems on daily activities and psychological and
work emotional affects
9b,c,d,f, Mental health Measures degree of nervousness, on daily activities
h depression and happiness levels
Data for analysis was collected from 284 participants as follows:

• 166 completed sets of data (completed pre and post SF36 forms)

• Missing data: 118 participants without complete data sets (info from pre and post
SF36 form) 35/284 missing pre course SF36 data and 83/284 missing post SF36
data.

The initial analysis was designed to explore whether there was a significant change in
SF-36 summary scores pre and post course
The Null Hypothesis being: There is no change in SF-36 Summary scores pre and post
course

Box plot of pre and post course SF-36 scores in the physical and mental health
domain.
 Physical & Mental Health Domain Summary Scores
100
80
SF-36 Score
40 20
0 60

pcs pcsPost
mcs mcsPost

PCS = Pre Physical component score PCSPost = Post Physical component

score
MCS = Pre Mental component score MCSPost = Post Mental component
score

The null hypothesis for the physical health domain can be rejected. The paired ttest
shows there is statistically significant difference between the pre and post physical
summary score.
p=0.00 (CI -20.01 -11.73)

The null hypothesis for the mental health domain can be rejected. The paired ttest
shows there is statistically significant difference between the pre and post mental
summary score.
p=0.00 (CI -22.07 - 13.05)

Comparison of the generic EPP courses with the healthy moves courses based on
the SF-36 physical and mental health summary scores.

This analysis is based on 5 of each course type, with 118 attendees.

Overall, all domains making up the physical and mental health component of the SF-36
demonstrated an improvement at post course intervention.
However, Healthy Moves exercise courses showed greatest improvements at increasing
overall SF 36 score.
Using multiple regression analysis to adjust for age group, baseline score, existing
health problems and gender, there was a significant difference in the physical health
summary score between the two course types.
Averege difference in score -11.3 (95% CI -19.7, -2.8) p = 0.010

The non-parametric Mann-Whitney test was used to assess whether there is a difference
in mental health summary scores between the two course types (as the assumptions for
linear regression were not met by the data). The Healthy Moves Course shows greatest
change in score.
The Mann-Whitney test shows there is a significant relationship between overall change
in pre/post mental health scores and course type Prob > |z| = 0.0356. This does not
adjust for other factors.