The General Practice Physical ActivityQuestionnaire (GPPAQ)

A screening tool to assess adult physical activity

levels within primary careUpdated May 2009DH INFORMATION READER BOXPolicy EstatesHR Workforce CommissioningManagement IM amp TPlanning FinanceClinical Social Care Partnership WorkingDocument PurposeGateway ReferenceTitleAuthorPublication DateTarget AudienceCirculation ListDescriptionCross RefSuperseded DocsAction RequiredTimingContact Details135-155 Waterloo RoadAn update to the General Practise Physical Activity Questionnaire ReportThis how to use guide has been made easier to use and now includes thenew read codes for patient record templates and is cross referenced toupdated policy including Be Active Be HealthyNAPhysical Activity Policy Health Improvement Directorate18 May 2009GPsDirectors of PHGPPAQ QuestionnaireGPPAQ Report 2006Replace GPPAQ Report 2006 with GPPAQ report 2009011854Best Practice GuidanceFor Recipients UseGeneral Practise Physical Activity QuestionnaireSE1 8UG020 7972 4544Jo FosterPhysical Activity Policy Team HIPWellington House

CONTENTS1 Executive Summary 3

2 The Case for Physical Activity for Health 5a CMO recommendations for physical activity 6b Current National Physical Activity Levels 63 The GPPAQ Screening Tool 7a Background 7b Intended Purpose 7c Tools for Practical Use in Primary Care 74 Instructions for use 9a How often to use 9b Exclusions for use 9c Completing the questionnaire 9d Analysing the Physical Activity Index 95 NICE Public Health Guidance Four Commonly Used Methods To IncreasePhysical Activity Brief Interventions 11a Brief intervention in physical activity 11b Physical Activity Care Pathway 12Annex 1a Calculating the Physical Activity Index 13b Summary of the Physical Activity Index 13c Combining responses for Physical Activity and Cycling 14d GPPAQ Read Codes 14Annex 2 17a Brief InterventionMotivational Interviewing within the Physical ActivityCare Pathwayb Inactive Patients who self report 3 hours or more per week of walkingAnnex 3 18GPPAQ Technical Background and EvaluationAnnex 4 21References21 Executive SummaryThe General Practise Physical Activity Questionnaire (GPPAQ) was commissionedby the DH and developed by the London School of Hygiene amp Tropical Medicine as avalidated short measure of physical activityThe GPPAQ was developed to assist Primary Care Trusts meet the National ServiceFramework recommendations that ldquoprimary care teams assess and record themodifiable risk factors for each of their patients including physical activityrdquoThe GPPAQ is a validated screening tool for use in primary care that1048707 Is used to assess adult (16 ndash 74 years) physical activity levels1048707 Provides a simple 4-level Physical Activity Index (PAI) categorising patients asActive Moderately Active Moderately Inactive and Inactive That is correlated toCVD risk1048707 Is used to help inform a practitioner of when a brief intervention to increasephysical activity is appropriate All patients who receive a score less than Activeshould be offered a brief intervention supporting behaviour change to increasePhysical Activity1048707 Can be used as part of the NHS Health Check programme to assess peoplersquosrisk of heart disease stroke kidney disease and diabetesIn response to the NICE Guidance 2006 endorsing Brief Interventions for PhysicalActivity in Primary Care the DH has now developed a Physical Activity Care

Pathway that uses the GPPAQ to screen patients for inactivity and then offers a BriefIntervention based on the principles of Motivational Interviewing to assist behaviourchange to all those classified as less than activeThe NICE guidance states that if (through validated screening tool such as GPPAQ)an individual is identified as less than active practitioners should offer a briefintervention in physical activity Which should include the followingrecommendations1048707 When providing physical activity advice primary care practitioners should takeinto account the individualrsquos needs preferences and circumstances1048707 They should agree goals with them They should also provide writteninformation about the benefits of activity and the local opportunities to beactive1048707 Where appropriate offer a referral into a condition specific or exercise onreferral programme if they exist in your area1048707 They should follow them up at appropriate intervals over a 3 to 6 monthperiod1048707 For those with CHD risk of greater than 30 over ten years GPPAQ shouldbe completed annuallyThe patients defined as lsquoActiversquo should receive a degree of verbal reinforcement thatreflects their current level of physical activity and should be encouraged to eithermake small increases to their physical activity or continue with their current levelFor those who are classified as ldquoless than activerdquo through the GPPAQ but say thatthey walk further investigation is required into the frequency and intensity If thepractitioner deems the patient sufficiently active protocol for an ldquoactiverdquo patient canfollow If unsure in any way or a patient expresses an interest in increasing theirphysical activity levels a brief intervention can be givenThe GPPAQ is also appropriate for use in the NHS Health Check programme whichwill assess peoplersquos risk of heart disease stroke kidney disease and diabetes andsupport people to reduce or manage that risk through individually tailored advice Ifthrough GPPAQ the individual is identified as less than active practitioners shouldoffer a brief intervention in physical activity

2 THE CASE FOR PHYSICAL ACTIVITY FOR HEALTHThe Chief Medical Officerrsquos report At least five a week published in 2004 set outthe important general health benefits associated with physical activity These werereflected in the recently published Be Active Be Healthy (2009) ndash A plan to get thenation movingPhysical activity can help all of us to lead healthier and even happier livesirrespective of age Even relatively small increases in physical activity areassociated with some protection against chronic disease and improved quality of lifeThe health benefits of physical activity are significant and well recognised Regularphysical activity of moderate intensity such as brisk walking can bring about majorhealth benefits as well as significant cost savings for the NHS Increasing levels ofphysical activity would contribute to achieving reductions in coronary heart diseaseand obesity hypertension depression and anxietyPeople who are physically active reduce their risk of developing major chronicdiseases ndash such as coronary heart disease stroke and type 2 diabetes ndash by up to50 and the risk of premature death by about 20ndash30Physical activity

bull is associated with a reduction in the overall risk of cancer has a clearprotective effect on colon cancer and is associated with a reduced risk ofbreast cancer in women after the menopausebull reduces the risk of diabetes ndash physically active people have a 33ndash50 lowerrisk of developing type 2 diabetes compared with inactive people with aparticularly strong preventive effect for those at high risk of developingdiabetesbull is important for helping people to maintain weight loss over several months oryears (Those who include physical activity as part of their weight loss planhave a better chance of long-term success Physical activity brings importantreductions in risk of mortality and morbidity for those who are alreadyoverweight or obese)bull can help protect against osteoporosis and have beneficial effects in those withosteoarthritis and low back painbull in childhood has a range of benefits including healthy growth anddevelopment maintenance of energy balance psychological well-being andsocial interaction and bull is associated with reduced risk of depression anddementia in later life is effective in the treatment of clinical depression andcan be as successful as psychotherapy or medication particularly in thelonger termMore generally physical activity helps people feel better and feel better aboutthemselves as well as helping to reduce physiological reactions to stress Thebenefits though can go well beyond our own health and well-being With highertransport costs and concerns about global warming more cycling and walking as5part of daily life can save money and help the environment Fewer car journeys canreduce traffic congestion and pollution feeding back into the health of communitiesPhysical activity also offers us opportunities for more social interaction ndash whether it isby joining a walking group being part of a team engaging in sport or simply leavingthe car at home for short local tripsA CHEIF MEDICAL OFFICER RECOMMENDATIONS FOR PHYSICAL ACTIVITYRecommendations for active living throughout the lifecourseFor general health benefits adults should achieve a total of at least 30 minutes a dayof at least moderate intensity physical activity on 5 or more days of the weekThe recommendations for adults are also appropriate for older adults Older peopleshould take particular care to keep moving and retain their mobility through dailyactivity Additionally specific activities that promote improved strength co-ordinationand balance are particularly beneficial for older peopleThe recommended levels of activity can be achieved either by doing all the dailyactivity in one session or through several shorter bouts of activity of 10 minutes ormore The activity can be lifestyle activity or structured exercise or sport or acombination of theseLifestyle activity means activities that are performed as part of everyday life such as climbing stairsor brisk walkingB CURRENT PHYSICAL ACTIVITY LEVELSCurrently 40 of men and 28 of women meet the Chief Medical Officerrsquosrecommendations for physical activity This represents an increase from levelsrecorded in 1997 (32 and 21 respectively) Health Survey for England 2007

Participation in physical activity declines significantly with age for both sexes whilethe prevalence of those achieving less than 30 minutes of at least moderate intensityactivity increases with age and is markedly higher in some groups Only 17 of menand 13 of women between the ages of 65 and 74 meet the Chief Medical Officerrsquosrecommendation for physical activity This drops to 8 and 3 of men and womenrespectively over the age of 75Levels of physical activity also show an association with ethnicity With the exceptionof Black Caribbean and Irish populations all other minority ethnic groups have lowerrates of adherence to the Chief Medical Officerrsquos recommendations on physicalactivity for adults Inequalities are greatest for South Asian women Only 11 ofBangladeshi and 14 of Pakistani women were reported to have done therecommended amounts of physical activity compared with 25 in the generalpopulationThe Public Health White Paper Choosing health Making healthier choices easierreiterated the commitment to develop a patient activity questionnaire to support NHSstaff and others to understand their patientsrsquo levels of physical activity63 THE GPPAQ SCREENING TOOLA BACKGROUNDIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivity which could be used in routine general practice to assist Primary CareTrusts to meet the National Service Framework recommendations that primary careteams assess and record the modifiable risk factors for each of their patientsincluding physical activityThis questionnaire is called the GP Physical Activity Questionnaire and wasvalidated for patients aged 16-74 as a screening tool for physical activity levels inprimary careB INTENDED PURPOSEThe General Practice Physical Activity Questionnaire (GPPAQ) is a validatedscreening tool that1048707 Is used to assess adult (16 ndash 74 years) physical activity levels1048707 Provides a simple 4-level Physical Activity Index (PAI) of Active ModeratelyActive Moderately Inactive and Inactive That is correlated to CVD risk1048707 Is used to help inform a practitioner of when a brief intervention to increasephysical activity is appropriate All patients who receive a score less than Activeshould be offered a Brief Intervention in Physical Activity (NICE Guidance 2006)1048707 Is a useful screening tool for the Vascular Risk Health Checks programmeAlthough the questionnaire includes walking DIY green exercise and houseworkthese are not reflected in the final score due to significant over reporting observedduring validation and further questioning of walking amount and walking intensity isrequired in order to confirm the need for a brief intervention Details of how to probethe walking question are set out in annex 2The GPPAQ is appropriate for use in the NHS Health Check programme which willassess peoplersquos risk of heart disease stroke kidney disease and diabetes andsupport people to reduce or manage that risk through individually tailored advice Ifthrough GPPAQ the individual is identified as less than active practitioners shouldoffer a brief intervention in physical activityC TOOLS FOR PRACTICAL USE IN PRIMARY CAREThe General Practice Physical Activity Questionnaire comprises

bull A written questionnaire for completion by patients if completed outside of theconsultationbull Electronic template of the questionnaire (Excel) which can be completed duringthe consultation and automatically generates the Physical Activity Index (PAI)bull Coding algorithm (See Appendix 1)bull Read Codes for the PAI which can be used in patient record templatesThe DH is planning to incorporate the GPPAQ algorithm within patient recordsoftware it is currently only available through bolt on package frontdesk Until then7the electronic template of the questionnaire can be saved as a separate file for eachpatientPlease note that the coding algorithm is an integral part of the questionnaireAny unauthorised modification to the coding algorithm is likely to negate thevalidation of the questionnaireThere are specific read codes for the Physical Activity Index which can be integratedinto locally created templates within patient recordsThe GPPAQ algorithm classifies patients into one of four categories physicalactivity indexes ndash active moderately active moderately inactive inactiveMore detail is available in Annex 184 INSTRUCTIONS FOR USE IN PRIMARY CAREA HOW OFTEN TO USEThe level of physical activity should be entered on the clinical record for all patientsover the age of sixteen and should be updated at least every five years1For patients with clinical evidence of occlusive arterial disease and those whose riskof CHD events is greater than 30 over ten years physical activity levels should berecorded annuallyB EXCLUSIONS FOR USEThe GPPAQ was not evaluated for use in children and young people (aged lt16years) or adults older than 74 years Both groups may require age-specific physicalactivity assessmentsThe GPPAQ has not been designed for use as a research tool to measure selfreportedphysical activity before and after interventions and therefore is notappropriate for measuring the effectiveness of physical activity interventionsC COMPLETING THE QUESTIONNAIREThe General Practice Physical Activity Questionnaire takes approximately 30seconds to fill inGPPAQ can be completed1048707 By patients waiting for appointments1048707 In disease specific clinics1048707 In routine consultations1048707 In activity clinicsIt then takes a maximum of 1-2 minutes to transfer the responses to the electronictemplate and analyse the result The template will automatically assign a PhysicalActivity IndexD ANALYSING THE PHYSICAL ACTIVITY INDEX (PAI)Questions concerning walking houseworkchildcare and gardeningDIY are includedHowever they have not been shown to yield data of a sufficient reliability tocontribute to an objective assessment of overall physical activity levels and are notincluded in the calculation of the PAI

Where patients have reported that they walk regularly and their PAI is less thanactive a discussion is needed around the amount of and intensity of walking Thiswill help to determine whether the patient is currently meeting the Chief MedicalOfficerrsquos recommendation for 30 minutes of moderate activity on 5 days of the week(or more)1 Department of Health (2000) National Service Framework for CoronaryHeart Disease London Department of Health Chapter 2 Appendix A9Walking Gardening (Green exercise) Housework DIY activities can contribute tomeeting the Chief Medical Officerrsquos recommendation and walking in particularshould be encouragedAll patients who receive a score of less than active should be offered a BriefIntervention in Physical Activity in line with the NICE Guidance (2006)1 05 NICE PUBLIC HEALTH GUIDANCE FOUR COMMONLY USED METHODS TOINCREASE PHYSICAL ACTIVITY BRIEF INTERVENTIONSA BRIEF INTERVENTION IN PHYSICAL ACTIVITYNICE Public Health Intervention Guidance published in March 2006 endorsed BriefInterventions in Physical ActivityThe recommendations stipulated that primary care practitioners should1048707 Take the opportunity whenever possible to identify inactive adults1048707 Advise them to aim for 30 minutes of moderate activity on 5 days of the week(or more)1048707 Use their judgement to determine when this would be inappropriate (forexample because of medical conditions or personal circumstances)1048707 Use a validated tool such as the Department of Healthrsquos general practitionerphysical activity questionnaire (GPPAQ) to identify inactive individualsThe group with most to gain from an increase in physical activity are those with a PAIof 1 ie the lsquoInactiversquo It is estimated that 9 of CHD could be avoided if all thosewho are sedentary and moderately inactive became more moderately activehttpwwwniceorgukGuidancePH2GuidancepdfEnglishKey pointsIf through the validated tool GPPAQ the individual is identified as less than activepractitioners should offer a brief intervention in physical activity1048707 When providing physical activity advice primary care practitioners should takeinto account the individualrsquos needs preferences and circumstances1048707 They should agree goals with them They should also provide writteninformation about the benefits of activity and the local opportunities to beactive1048707 Where appropriate offer a referral into a condition specific or exercise onreferral programme if they are available locally1048707 They should follow them up at appropriate intervals over a 3 to 6 monthperiod1048707 Those with CHD risk of greater than 30 over ten years GPPAQ should becompleted annuallyThe lsquoActiversquo group should receive a degree of verbal reinforcement that reflects theircurrent level of physical activity and should be encouraged to either make smallincreases or continue with their current physical activity levelFor those who are classified as ldquoless than activerdquo through the GPPAQ but say thatthey walk further investigation is required into the frequency and intensity If the

practitioner deems the patient sufficiently active protocol for an ldquoactiverdquo patient canfollow For those who are still deemed inactive or unsure if they meet the CMOrecommendations or if a patient still expresses interest in increasing their physicalactivity levels a brief intervention can be given For details about how to discusswalking in greater detail please see Annex 21 1B PHYSICAL ACTIVITY CARE PATHWAYThe Department of Health has developed a Physical Activity Care Pathway to helpprimary care deliver the NICE Guidance for Brief InterventionsThis1048707 Uses the GPPAQ to screen patients for inactivity1048707 Follows the NICE guidance protocols detailed above to deliver a briefintervention including patient follow up at 36 and 12 months1048707 Uses the evidence based behaviour change technique MotivationalInterviewing to deliver the brief interventionThe Physical Activity Care Pathway has been positively evaluated by the BritishHeart Foundation National Centre for Physical Activity and Health at LoughboroughUniversity in a feasibility study in 14 surgeries that concluded in September 2008The Department of Health plans to launch the Physical Activity Care Pathwayresources in late 2009 This will include a commissioning toolkit and how to guide atraining package and patient resource pack1 2ANNEX 1A CALCULATING THE 4-LEVEL PHYSICAL ACTIVITY INDEX (PAI)Patients can be classified into four categories based on the original EPIC index fromwhich the GPPAQ was developedInactive Sedentary job and no physical exercise or cyclingModerately inactive Sedentary job and some but lt 1 hour physical exercise and orcycling per week ORStanding job and no physical exercise or cyclingModerately active Sedentary job and 1-29 hours physical exercise and or cyclingper week ORStanding job and some but lt 1 hour physical exercise and orcycling per week ORPhysical job and no physical exercise or cyclingActive Sedentary job and ge 3 hours physical exercise and or cyclingper week ORStanding job and 1-29 hours physical exercise and or cyclingper week ORPhysical job and some but lt 1 hour physical exercise and orcycling per week ORHeavy manual jobNote Questions concerning Walking HouseworkChildcare and GardeningDIY havebeen included to allow patients to record their physical activity in these categorieshowever these questions have not been shown to yield data of a sufficient reliabilityto contribute to an understanding of overall physical activity levels As noted abovefurther questioning is requiredB SUMMARY OF THE PAIOccupationPhysical exercise and or

cycling (hrwk)Sedentary Standing Physical Heavy Manual0 Inactive ModeratelyInactiveModeratelyActiveActiveSome but lt 1 ModeratelyInactiveModeratelyActiveActive Active1-29 ModeratelyActiveActive Active Activege 3 Active Active Active Active1 3C COMBINING RESPONSES FOR PHYSICAL EXERCISE AND CYCLINGCyclingPhysicalExercise0 Some but lt 1 1-29 ge30 0 Some but lt 1 1-29 ge3Some but lt 1 Some but lt 1 1-29 ge3 ge31-29 1-29 ge3 ge3 ge3ge3 ge3 ge3 ge3 ge3D GPPAQ READ CODES4 Byte Version 2 CTV3138X | GPPAQphyscl act indinactive138X | Generalpractice physicalactivity questionnairephysical activityindex inactiveXaPP8 | General practicephysical activityquestionnaire physicalactivity index inactive366121000000108 | General practicephysical activity questionnaire physicalactivity index inactive (finding)138Y | GPPAQphys act ind modinactv138Y | Generalpractice physicalactivity questionnairephysical activityindex moderatelyinactiveXaPPB | General practicephysical activityquestionnaire physicalactivity index moderately

inactive366171000000107 | General practicephysical activity questionnaire physicalactivity index moderately inactive(finding)138a | GPPAQphys act ind modactive138a | Generalpractice physicalactivity questionnairephysical activityindex moderatelyactiveXaPPD | General practicephysical activityquestionnaire physicalactivity index moderatelyactive366211000000105 | General practicephysical activity questionnaire physicalactivity index moderately active(finding)138b | GPPAQphysical act indactive138b | Generalpractice physicalactivity questionnairephysical activityindex activeXaPPE | General practicephysical activityquestionnaire physicalactivity index active366241000000106 | General practicephysical activity questionnaire physicalactivity index active (finding)1 4ANNEX 2A AN EXAMPLE OF A MOTIVATIONAL INTERVIEW WITHIN APHYSICAL ACTIVITY BRIEF INTERVENTIONPractitioners can consider the following example of a brief verbal intervention forInactive patients based on the principles of Motivational Interviewing (MI)Any intervention should be consistent with the agenda on patient led consultations andchoice One way to do this is to base behaviour-change negotiations on the principles ofmotivational interviewing (MI) Although developed in the field of addictions brief versions ofMI have been adapted and applied to a wide variety of behaviours and conditions such assmoking diet physical activity medical adherence and diabetes with evidence ofeffectiveness (Resnicow et al 2002 Rollnick 1999 Rubak 2005)Motivational Interviewing elicits change talk in the patient empowering them tochange their own behaviour Below are example questions for an MI based dialogueExample Dialogue for Inactive PatientsQuestion set OneldquoOn a scale from 0 to 10 where 0 is not important at all and 10 is extremely

important how important is getting more active for yourdquoldquoWhy did you pick this numberldquoldquoWhy did you not pick a lower numberldquoldquoWhat would you need to do to get you to a higher numberrdquoQuestion set TwoldquoNow think about why you want to do this Think about how yoursquoll feel whatyoursquoll look like what yoursquoll be able to do that you canrsquot do now Also thinkabout what might be stopping you from changing and what will happen if youdonrsquotrdquoWhy you want to changeeg To be able to play with children grandchildren To help healthWhat will happen if you changeeg more energy less lonely control conditionWhy you donrsquot want to changeeg low confidence donrsquot think will enjoy itWhat will happen if you donrsquoteg condition will get worse feel bad about self not be able to play withchildrengrandchildrenQuestion set ThreelsquoIf you were to decide to increase your physical activity how confident areyou that you would succeed If on a scale of 0 to 10 0 means that you are1 5not at all confident and 10 means that you are 100 confident you couldbecome more active What number would you give yourselfrdquoWhy did you pick this number on the scaleWhy did you not pick a lower numberWhat would you need to do to get a higher numberAll the while yoursquore trying elicit change talk from them and reaffirm these statementsback to the patientFinally provide the patient with a brief summary of what you heard and then askldquoWhat do you think the next step is for yourdquoYou can talk about the patients day and work with the patient about when activitycould be built in eg getting off the bus a stop early or walking children to schoolAnd also talk about activities that might be of interest to the patient whether itrsquosgardening dance swimming cycling walking or footballA common response is for the patient to say they donrsquot know or are uncertain If theydo follow withldquoLetrsquos list what the options are at the moment You couldStay as you are and do nothingStart to increase the amount of physical activity that you dordquoAgain this should illicit change talkGo through the patients day with them and talk about when activity could bebuilt in eg getting off the bus a stop early joining in a health walk or walkingthe children to schoolAlso talk about what activities might be of interest to them signpost to localactivities from gardening to dance to footballAsk the patient what they make of these opportunitiesIf interested talk to the patient about appropriate levels of activity and how tobuild up their activity levels If someone hasnrsquot been active for a long timegoing straight into vigorous activity isnrsquot a good idea advise patients to build

up their activity levels and intensity graduallyEncourage a patient to set a specific goal such asldquoI will go for a walk on Tuesday at lunchtime at the park for thirty minutes If Icanrsquot make it then I will go on WednesdayrdquoIn just a few minutes it is possible to encourage the patient to consider why and howthey might change their physical activity without feeling as if they are being pushedor coerced into something they are not ready for(Dialogue based on Rollnick et al 1997 Miller 2005 Rollnick et al 2005)1 6B ASSESSING INACTIVE PATIENTS WHO SELF REPORT 3 HOURSOR MORE PER WEEK OF WALKINGPatients who fall within the inactive category but claim to undertake significantamounts of walking may require a modified brief intervention that probes theirunderstanding of walking and walking pace and the basis upon which they havedeclared the amount of walking accumulated during the last week For those patientswho remain confident that they achieve the recommended levels of physical activityby virtue of their walking intensity and duration encourage them to continue Theexample dialogue given for Inactive patients could be prefaced with the followingldquoYou say you do three hours or more of walking per week So that I mightbetter understand how walking fits into your day perhaps you could talk methrough a typical day for you starting from when you get up in the morningright through to when you go to bed telling me where walking fits in Howabout yesterday could you talk me through yesterdayrdquoIf the patient insists the previous day was atypical use the day before that Try toavoid going too far back as the accuracy of recall will be diminished Thepractitionerrsquos task in this exercise is simply to listen without offering any judgementof what is being said This is not further assessment of the patientrsquos activity The aimis to get the patient talking about their current behaviour in a non-threatening (thethreat of being told to change) environment that will build rapport and conveys to thepatient that the practitioner listens and is genuinely interested in their situationEnsure you assess the level of intensity of walking you can use the following tool toassess intensity0 breathing easily conversation is easy1 breathing lightly and talking easily but heart rate increases2 still talking comfortably but breathing more quickly body warming up3 breathing more deeply and harder talking with a little more difficulty4 breathing very hard and short of breath cannot carry on a conversationLight Activity 0-1 Moderate Activity 2-3 Vigorous Activity 4Patients should be hitting 2-3 for the walking to count towards their activity levelOnce the patient has completed the description of their day the practitioner shouldsimply summarise the information on walking and then proceed to the motivation andconfidence questions described above as appropriate1 7ANNEX 3 GPPAQ TECHNICAL BACKGROUND AND EVALUATIONIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivityThe measure was intended for use in routine general practice and its purpose was toprovide a simple 4-level Physical Activity Index (PAI) reflecting an individualrsquos currentphysical activity The index would be used to decide when interventions to increase

physical activity might be appropriate A working title for the measure was theGeneral Practice Physical Activity Questionnaire (GPPAQ)After reviewing the literature and consultation with experts performancerequirements for the GPPAQ were agreed These were thatbull The method of completion should be self explanatorybull It should be designed for use by adults aged 18-74 years (later revised to 16-74 years)bull It should be possible for respondents to complete the questionnaire withoutassistancebull It should take less than one minute to completebull Individual physical activity categories should be simple requiring limitedcomputationbull The physical activity categories should allow for the assignment of a physicalactivity Read Codebull The output of the questionnaire should enable practice staff to make adecision on whether the patient concerned should be advised to be moreactive or whether more detailed assessment was requiredAlthough no existing self-report measure of physical activity had specifically beendeveloped for routine general practice a short physical activity questionnaire used inthe European Prospective Investigation into Cancer (EPIC) met many of the criteriaand a simple index of physical activity could be derived It had establishedacceptable levels of repeatability and validity in a sample of English adults aged 40-65 years (Wareham et al 2002) It was decided that this short questionnaire shouldform the basis of the new measureA pilot study was conducted in three general practices with practice nursesadministering the self-completion of GPPAQ to 61 patients from a variety of newlyregistered patients including a number of patients for whom English was not the firstlanguage The GPPAQ was well received by nurses patients and generalpractitioners Practitioners welcomed a simple and efficient way of assessingphysical activity In particular they were keen to have a standardised way ofassigning Read Codes for physical activity The patients did not experience anyproblems in completing the questionnaire even when English was not the firstlanguageThe pilot study was limited to new registration appointments but most practitionerssuggested other possible uses for the GPPAQ including hypertension and diabetesclinics1 8Due to the positive findings of the pilot study a further study was conducted toexamine how reliable and accurate the GPPAQ was in routine general practice Foursurgeries were recruited in Coventry West Midlands Table 2 summarises thesurgeriesTable 2 Summary of study surgeriesPractice 1RegisteredpatientsNumberof GPsPatientCharacteristics1 10600 6

Mixed income70 white2 - -Low incomeMainly white3 11500 6Middle incomeMainly white4 - -Low income50 white5 14400 9Mixed income70 white6 6450 3Mixed incomeMainly whiteNB Practices 1 and 2 have two locations as do Practices 3 and 4

A Research Fellow (RF) of the University of Warwick recruited patients in the waitingrooms of the four surgeries The timing of recruiting visits to the surgeries wasvaried The routine nature of the recruitment meant that study participants werethose who normally attend general practice A total of 334 participants successfullycompleted the GPPAQ and a total of 258 participants completed it again a weeklater The PAI category allocated to each individual resulting from the completion ofthe second GPPAQ was compared with allocation to a physical activity categoryresulting from analysis of activity recorded for the same individual during thepreceding week using an Actigraph motion sensor Demographic characteristics ofparticipants who completed the first GPPAQ are summarised in Table 2Table 3 Participant characteristicsN GenderMaleFemale109223328672Age group18-2425-3435-4445-5455-6465-74226167746543

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

2 The Case for Physical Activity for Health 5a CMO recommendations for physical activity 6b Current National Physical Activity Levels 63 The GPPAQ Screening Tool 7a Background 7b Intended Purpose 7c Tools for Practical Use in Primary Care 74 Instructions for use 9a How often to use 9b Exclusions for use 9c Completing the questionnaire 9d Analysing the Physical Activity Index 95 NICE Public Health Guidance Four Commonly Used Methods To IncreasePhysical Activity Brief Interventions 11a Brief intervention in physical activity 11b Physical Activity Care Pathway 12Annex 1a Calculating the Physical Activity Index 13b Summary of the Physical Activity Index 13c Combining responses for Physical Activity and Cycling 14d GPPAQ Read Codes 14Annex 2 17a Brief InterventionMotivational Interviewing within the Physical ActivityCare Pathwayb Inactive Patients who self report 3 hours or more per week of walkingAnnex 3 18GPPAQ Technical Background and EvaluationAnnex 4 21References21 Executive SummaryThe General Practise Physical Activity Questionnaire (GPPAQ) was commissionedby the DH and developed by the London School of Hygiene amp Tropical Medicine as avalidated short measure of physical activityThe GPPAQ was developed to assist Primary Care Trusts meet the National ServiceFramework recommendations that ldquoprimary care teams assess and record themodifiable risk factors for each of their patients including physical activityrdquoThe GPPAQ is a validated screening tool for use in primary care that1048707 Is used to assess adult (16 ndash 74 years) physical activity levels1048707 Provides a simple 4-level Physical Activity Index (PAI) categorising patients asActive Moderately Active Moderately Inactive and Inactive That is correlated toCVD risk1048707 Is used to help inform a practitioner of when a brief intervention to increasephysical activity is appropriate All patients who receive a score less than Activeshould be offered a brief intervention supporting behaviour change to increasePhysical Activity1048707 Can be used as part of the NHS Health Check programme to assess peoplersquosrisk of heart disease stroke kidney disease and diabetesIn response to the NICE Guidance 2006 endorsing Brief Interventions for PhysicalActivity in Primary Care the DH has now developed a Physical Activity Care

Pathway that uses the GPPAQ to screen patients for inactivity and then offers a BriefIntervention based on the principles of Motivational Interviewing to assist behaviourchange to all those classified as less than activeThe NICE guidance states that if (through validated screening tool such as GPPAQ)an individual is identified as less than active practitioners should offer a briefintervention in physical activity Which should include the followingrecommendations1048707 When providing physical activity advice primary care practitioners should takeinto account the individualrsquos needs preferences and circumstances1048707 They should agree goals with them They should also provide writteninformation about the benefits of activity and the local opportunities to beactive1048707 Where appropriate offer a referral into a condition specific or exercise onreferral programme if they exist in your area1048707 They should follow them up at appropriate intervals over a 3 to 6 monthperiod1048707 For those with CHD risk of greater than 30 over ten years GPPAQ shouldbe completed annuallyThe patients defined as lsquoActiversquo should receive a degree of verbal reinforcement thatreflects their current level of physical activity and should be encouraged to eithermake small increases to their physical activity or continue with their current levelFor those who are classified as ldquoless than activerdquo through the GPPAQ but say thatthey walk further investigation is required into the frequency and intensity If thepractitioner deems the patient sufficiently active protocol for an ldquoactiverdquo patient canfollow If unsure in any way or a patient expresses an interest in increasing theirphysical activity levels a brief intervention can be givenThe GPPAQ is also appropriate for use in the NHS Health Check programme whichwill assess peoplersquos risk of heart disease stroke kidney disease and diabetes andsupport people to reduce or manage that risk through individually tailored advice Ifthrough GPPAQ the individual is identified as less than active practitioners shouldoffer a brief intervention in physical activity

2 THE CASE FOR PHYSICAL ACTIVITY FOR HEALTHThe Chief Medical Officerrsquos report At least five a week published in 2004 set outthe important general health benefits associated with physical activity These werereflected in the recently published Be Active Be Healthy (2009) ndash A plan to get thenation movingPhysical activity can help all of us to lead healthier and even happier livesirrespective of age Even relatively small increases in physical activity areassociated with some protection against chronic disease and improved quality of lifeThe health benefits of physical activity are significant and well recognised Regularphysical activity of moderate intensity such as brisk walking can bring about majorhealth benefits as well as significant cost savings for the NHS Increasing levels ofphysical activity would contribute to achieving reductions in coronary heart diseaseand obesity hypertension depression and anxietyPeople who are physically active reduce their risk of developing major chronicdiseases ndash such as coronary heart disease stroke and type 2 diabetes ndash by up to50 and the risk of premature death by about 20ndash30Physical activity

bull is associated with a reduction in the overall risk of cancer has a clearprotective effect on colon cancer and is associated with a reduced risk ofbreast cancer in women after the menopausebull reduces the risk of diabetes ndash physically active people have a 33ndash50 lowerrisk of developing type 2 diabetes compared with inactive people with aparticularly strong preventive effect for those at high risk of developingdiabetesbull is important for helping people to maintain weight loss over several months oryears (Those who include physical activity as part of their weight loss planhave a better chance of long-term success Physical activity brings importantreductions in risk of mortality and morbidity for those who are alreadyoverweight or obese)bull can help protect against osteoporosis and have beneficial effects in those withosteoarthritis and low back painbull in childhood has a range of benefits including healthy growth anddevelopment maintenance of energy balance psychological well-being andsocial interaction and bull is associated with reduced risk of depression anddementia in later life is effective in the treatment of clinical depression andcan be as successful as psychotherapy or medication particularly in thelonger termMore generally physical activity helps people feel better and feel better aboutthemselves as well as helping to reduce physiological reactions to stress Thebenefits though can go well beyond our own health and well-being With highertransport costs and concerns about global warming more cycling and walking as5part of daily life can save money and help the environment Fewer car journeys canreduce traffic congestion and pollution feeding back into the health of communitiesPhysical activity also offers us opportunities for more social interaction ndash whether it isby joining a walking group being part of a team engaging in sport or simply leavingthe car at home for short local tripsA CHEIF MEDICAL OFFICER RECOMMENDATIONS FOR PHYSICAL ACTIVITYRecommendations for active living throughout the lifecourseFor general health benefits adults should achieve a total of at least 30 minutes a dayof at least moderate intensity physical activity on 5 or more days of the weekThe recommendations for adults are also appropriate for older adults Older peopleshould take particular care to keep moving and retain their mobility through dailyactivity Additionally specific activities that promote improved strength co-ordinationand balance are particularly beneficial for older peopleThe recommended levels of activity can be achieved either by doing all the dailyactivity in one session or through several shorter bouts of activity of 10 minutes ormore The activity can be lifestyle activity or structured exercise or sport or acombination of theseLifestyle activity means activities that are performed as part of everyday life such as climbing stairsor brisk walkingB CURRENT PHYSICAL ACTIVITY LEVELSCurrently 40 of men and 28 of women meet the Chief Medical Officerrsquosrecommendations for physical activity This represents an increase from levelsrecorded in 1997 (32 and 21 respectively) Health Survey for England 2007

Participation in physical activity declines significantly with age for both sexes whilethe prevalence of those achieving less than 30 minutes of at least moderate intensityactivity increases with age and is markedly higher in some groups Only 17 of menand 13 of women between the ages of 65 and 74 meet the Chief Medical Officerrsquosrecommendation for physical activity This drops to 8 and 3 of men and womenrespectively over the age of 75Levels of physical activity also show an association with ethnicity With the exceptionof Black Caribbean and Irish populations all other minority ethnic groups have lowerrates of adherence to the Chief Medical Officerrsquos recommendations on physicalactivity for adults Inequalities are greatest for South Asian women Only 11 ofBangladeshi and 14 of Pakistani women were reported to have done therecommended amounts of physical activity compared with 25 in the generalpopulationThe Public Health White Paper Choosing health Making healthier choices easierreiterated the commitment to develop a patient activity questionnaire to support NHSstaff and others to understand their patientsrsquo levels of physical activity63 THE GPPAQ SCREENING TOOLA BACKGROUNDIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivity which could be used in routine general practice to assist Primary CareTrusts to meet the National Service Framework recommendations that primary careteams assess and record the modifiable risk factors for each of their patientsincluding physical activityThis questionnaire is called the GP Physical Activity Questionnaire and wasvalidated for patients aged 16-74 as a screening tool for physical activity levels inprimary careB INTENDED PURPOSEThe General Practice Physical Activity Questionnaire (GPPAQ) is a validatedscreening tool that1048707 Is used to assess adult (16 ndash 74 years) physical activity levels1048707 Provides a simple 4-level Physical Activity Index (PAI) of Active ModeratelyActive Moderately Inactive and Inactive That is correlated to CVD risk1048707 Is used to help inform a practitioner of when a brief intervention to increasephysical activity is appropriate All patients who receive a score less than Activeshould be offered a Brief Intervention in Physical Activity (NICE Guidance 2006)1048707 Is a useful screening tool for the Vascular Risk Health Checks programmeAlthough the questionnaire includes walking DIY green exercise and houseworkthese are not reflected in the final score due to significant over reporting observedduring validation and further questioning of walking amount and walking intensity isrequired in order to confirm the need for a brief intervention Details of how to probethe walking question are set out in annex 2The GPPAQ is appropriate for use in the NHS Health Check programme which willassess peoplersquos risk of heart disease stroke kidney disease and diabetes andsupport people to reduce or manage that risk through individually tailored advice Ifthrough GPPAQ the individual is identified as less than active practitioners shouldoffer a brief intervention in physical activityC TOOLS FOR PRACTICAL USE IN PRIMARY CAREThe General Practice Physical Activity Questionnaire comprises

bull A written questionnaire for completion by patients if completed outside of theconsultationbull Electronic template of the questionnaire (Excel) which can be completed duringthe consultation and automatically generates the Physical Activity Index (PAI)bull Coding algorithm (See Appendix 1)bull Read Codes for the PAI which can be used in patient record templatesThe DH is planning to incorporate the GPPAQ algorithm within patient recordsoftware it is currently only available through bolt on package frontdesk Until then7the electronic template of the questionnaire can be saved as a separate file for eachpatientPlease note that the coding algorithm is an integral part of the questionnaireAny unauthorised modification to the coding algorithm is likely to negate thevalidation of the questionnaireThere are specific read codes for the Physical Activity Index which can be integratedinto locally created templates within patient recordsThe GPPAQ algorithm classifies patients into one of four categories physicalactivity indexes ndash active moderately active moderately inactive inactiveMore detail is available in Annex 184 INSTRUCTIONS FOR USE IN PRIMARY CAREA HOW OFTEN TO USEThe level of physical activity should be entered on the clinical record for all patientsover the age of sixteen and should be updated at least every five years1For patients with clinical evidence of occlusive arterial disease and those whose riskof CHD events is greater than 30 over ten years physical activity levels should berecorded annuallyB EXCLUSIONS FOR USEThe GPPAQ was not evaluated for use in children and young people (aged lt16years) or adults older than 74 years Both groups may require age-specific physicalactivity assessmentsThe GPPAQ has not been designed for use as a research tool to measure selfreportedphysical activity before and after interventions and therefore is notappropriate for measuring the effectiveness of physical activity interventionsC COMPLETING THE QUESTIONNAIREThe General Practice Physical Activity Questionnaire takes approximately 30seconds to fill inGPPAQ can be completed1048707 By patients waiting for appointments1048707 In disease specific clinics1048707 In routine consultations1048707 In activity clinicsIt then takes a maximum of 1-2 minutes to transfer the responses to the electronictemplate and analyse the result The template will automatically assign a PhysicalActivity IndexD ANALYSING THE PHYSICAL ACTIVITY INDEX (PAI)Questions concerning walking houseworkchildcare and gardeningDIY are includedHowever they have not been shown to yield data of a sufficient reliability tocontribute to an objective assessment of overall physical activity levels and are notincluded in the calculation of the PAI

Where patients have reported that they walk regularly and their PAI is less thanactive a discussion is needed around the amount of and intensity of walking Thiswill help to determine whether the patient is currently meeting the Chief MedicalOfficerrsquos recommendation for 30 minutes of moderate activity on 5 days of the week(or more)1 Department of Health (2000) National Service Framework for CoronaryHeart Disease London Department of Health Chapter 2 Appendix A9Walking Gardening (Green exercise) Housework DIY activities can contribute tomeeting the Chief Medical Officerrsquos recommendation and walking in particularshould be encouragedAll patients who receive a score of less than active should be offered a BriefIntervention in Physical Activity in line with the NICE Guidance (2006)1 05 NICE PUBLIC HEALTH GUIDANCE FOUR COMMONLY USED METHODS TOINCREASE PHYSICAL ACTIVITY BRIEF INTERVENTIONSA BRIEF INTERVENTION IN PHYSICAL ACTIVITYNICE Public Health Intervention Guidance published in March 2006 endorsed BriefInterventions in Physical ActivityThe recommendations stipulated that primary care practitioners should1048707 Take the opportunity whenever possible to identify inactive adults1048707 Advise them to aim for 30 minutes of moderate activity on 5 days of the week(or more)1048707 Use their judgement to determine when this would be inappropriate (forexample because of medical conditions or personal circumstances)1048707 Use a validated tool such as the Department of Healthrsquos general practitionerphysical activity questionnaire (GPPAQ) to identify inactive individualsThe group with most to gain from an increase in physical activity are those with a PAIof 1 ie the lsquoInactiversquo It is estimated that 9 of CHD could be avoided if all thosewho are sedentary and moderately inactive became more moderately activehttpwwwniceorgukGuidancePH2GuidancepdfEnglishKey pointsIf through the validated tool GPPAQ the individual is identified as less than activepractitioners should offer a brief intervention in physical activity1048707 When providing physical activity advice primary care practitioners should takeinto account the individualrsquos needs preferences and circumstances1048707 They should agree goals with them They should also provide writteninformation about the benefits of activity and the local opportunities to beactive1048707 Where appropriate offer a referral into a condition specific or exercise onreferral programme if they are available locally1048707 They should follow them up at appropriate intervals over a 3 to 6 monthperiod1048707 Those with CHD risk of greater than 30 over ten years GPPAQ should becompleted annuallyThe lsquoActiversquo group should receive a degree of verbal reinforcement that reflects theircurrent level of physical activity and should be encouraged to either make smallincreases or continue with their current physical activity levelFor those who are classified as ldquoless than activerdquo through the GPPAQ but say thatthey walk further investigation is required into the frequency and intensity If the

practitioner deems the patient sufficiently active protocol for an ldquoactiverdquo patient canfollow For those who are still deemed inactive or unsure if they meet the CMOrecommendations or if a patient still expresses interest in increasing their physicalactivity levels a brief intervention can be given For details about how to discusswalking in greater detail please see Annex 21 1B PHYSICAL ACTIVITY CARE PATHWAYThe Department of Health has developed a Physical Activity Care Pathway to helpprimary care deliver the NICE Guidance for Brief InterventionsThis1048707 Uses the GPPAQ to screen patients for inactivity1048707 Follows the NICE guidance protocols detailed above to deliver a briefintervention including patient follow up at 36 and 12 months1048707 Uses the evidence based behaviour change technique MotivationalInterviewing to deliver the brief interventionThe Physical Activity Care Pathway has been positively evaluated by the BritishHeart Foundation National Centre for Physical Activity and Health at LoughboroughUniversity in a feasibility study in 14 surgeries that concluded in September 2008The Department of Health plans to launch the Physical Activity Care Pathwayresources in late 2009 This will include a commissioning toolkit and how to guide atraining package and patient resource pack1 2ANNEX 1A CALCULATING THE 4-LEVEL PHYSICAL ACTIVITY INDEX (PAI)Patients can be classified into four categories based on the original EPIC index fromwhich the GPPAQ was developedInactive Sedentary job and no physical exercise or cyclingModerately inactive Sedentary job and some but lt 1 hour physical exercise and orcycling per week ORStanding job and no physical exercise or cyclingModerately active Sedentary job and 1-29 hours physical exercise and or cyclingper week ORStanding job and some but lt 1 hour physical exercise and orcycling per week ORPhysical job and no physical exercise or cyclingActive Sedentary job and ge 3 hours physical exercise and or cyclingper week ORStanding job and 1-29 hours physical exercise and or cyclingper week ORPhysical job and some but lt 1 hour physical exercise and orcycling per week ORHeavy manual jobNote Questions concerning Walking HouseworkChildcare and GardeningDIY havebeen included to allow patients to record their physical activity in these categorieshowever these questions have not been shown to yield data of a sufficient reliabilityto contribute to an understanding of overall physical activity levels As noted abovefurther questioning is requiredB SUMMARY OF THE PAIOccupationPhysical exercise and or

cycling (hrwk)Sedentary Standing Physical Heavy Manual0 Inactive ModeratelyInactiveModeratelyActiveActiveSome but lt 1 ModeratelyInactiveModeratelyActiveActive Active1-29 ModeratelyActiveActive Active Activege 3 Active Active Active Active1 3C COMBINING RESPONSES FOR PHYSICAL EXERCISE AND CYCLINGCyclingPhysicalExercise0 Some but lt 1 1-29 ge30 0 Some but lt 1 1-29 ge3Some but lt 1 Some but lt 1 1-29 ge3 ge31-29 1-29 ge3 ge3 ge3ge3 ge3 ge3 ge3 ge3D GPPAQ READ CODES4 Byte Version 2 CTV3138X | GPPAQphyscl act indinactive138X | Generalpractice physicalactivity questionnairephysical activityindex inactiveXaPP8 | General practicephysical activityquestionnaire physicalactivity index inactive366121000000108 | General practicephysical activity questionnaire physicalactivity index inactive (finding)138Y | GPPAQphys act ind modinactv138Y | Generalpractice physicalactivity questionnairephysical activityindex moderatelyinactiveXaPPB | General practicephysical activityquestionnaire physicalactivity index moderately

inactive366171000000107 | General practicephysical activity questionnaire physicalactivity index moderately inactive(finding)138a | GPPAQphys act ind modactive138a | Generalpractice physicalactivity questionnairephysical activityindex moderatelyactiveXaPPD | General practicephysical activityquestionnaire physicalactivity index moderatelyactive366211000000105 | General practicephysical activity questionnaire physicalactivity index moderately active(finding)138b | GPPAQphysical act indactive138b | Generalpractice physicalactivity questionnairephysical activityindex activeXaPPE | General practicephysical activityquestionnaire physicalactivity index active366241000000106 | General practicephysical activity questionnaire physicalactivity index active (finding)1 4ANNEX 2A AN EXAMPLE OF A MOTIVATIONAL INTERVIEW WITHIN APHYSICAL ACTIVITY BRIEF INTERVENTIONPractitioners can consider the following example of a brief verbal intervention forInactive patients based on the principles of Motivational Interviewing (MI)Any intervention should be consistent with the agenda on patient led consultations andchoice One way to do this is to base behaviour-change negotiations on the principles ofmotivational interviewing (MI) Although developed in the field of addictions brief versions ofMI have been adapted and applied to a wide variety of behaviours and conditions such assmoking diet physical activity medical adherence and diabetes with evidence ofeffectiveness (Resnicow et al 2002 Rollnick 1999 Rubak 2005)Motivational Interviewing elicits change talk in the patient empowering them tochange their own behaviour Below are example questions for an MI based dialogueExample Dialogue for Inactive PatientsQuestion set OneldquoOn a scale from 0 to 10 where 0 is not important at all and 10 is extremely

important how important is getting more active for yourdquoldquoWhy did you pick this numberldquoldquoWhy did you not pick a lower numberldquoldquoWhat would you need to do to get you to a higher numberrdquoQuestion set TwoldquoNow think about why you want to do this Think about how yoursquoll feel whatyoursquoll look like what yoursquoll be able to do that you canrsquot do now Also thinkabout what might be stopping you from changing and what will happen if youdonrsquotrdquoWhy you want to changeeg To be able to play with children grandchildren To help healthWhat will happen if you changeeg more energy less lonely control conditionWhy you donrsquot want to changeeg low confidence donrsquot think will enjoy itWhat will happen if you donrsquoteg condition will get worse feel bad about self not be able to play withchildrengrandchildrenQuestion set ThreelsquoIf you were to decide to increase your physical activity how confident areyou that you would succeed If on a scale of 0 to 10 0 means that you are1 5not at all confident and 10 means that you are 100 confident you couldbecome more active What number would you give yourselfrdquoWhy did you pick this number on the scaleWhy did you not pick a lower numberWhat would you need to do to get a higher numberAll the while yoursquore trying elicit change talk from them and reaffirm these statementsback to the patientFinally provide the patient with a brief summary of what you heard and then askldquoWhat do you think the next step is for yourdquoYou can talk about the patients day and work with the patient about when activitycould be built in eg getting off the bus a stop early or walking children to schoolAnd also talk about activities that might be of interest to the patient whether itrsquosgardening dance swimming cycling walking or footballA common response is for the patient to say they donrsquot know or are uncertain If theydo follow withldquoLetrsquos list what the options are at the moment You couldStay as you are and do nothingStart to increase the amount of physical activity that you dordquoAgain this should illicit change talkGo through the patients day with them and talk about when activity could bebuilt in eg getting off the bus a stop early joining in a health walk or walkingthe children to schoolAlso talk about what activities might be of interest to them signpost to localactivities from gardening to dance to footballAsk the patient what they make of these opportunitiesIf interested talk to the patient about appropriate levels of activity and how tobuild up their activity levels If someone hasnrsquot been active for a long timegoing straight into vigorous activity isnrsquot a good idea advise patients to build

up their activity levels and intensity graduallyEncourage a patient to set a specific goal such asldquoI will go for a walk on Tuesday at lunchtime at the park for thirty minutes If Icanrsquot make it then I will go on WednesdayrdquoIn just a few minutes it is possible to encourage the patient to consider why and howthey might change their physical activity without feeling as if they are being pushedor coerced into something they are not ready for(Dialogue based on Rollnick et al 1997 Miller 2005 Rollnick et al 2005)1 6B ASSESSING INACTIVE PATIENTS WHO SELF REPORT 3 HOURSOR MORE PER WEEK OF WALKINGPatients who fall within the inactive category but claim to undertake significantamounts of walking may require a modified brief intervention that probes theirunderstanding of walking and walking pace and the basis upon which they havedeclared the amount of walking accumulated during the last week For those patientswho remain confident that they achieve the recommended levels of physical activityby virtue of their walking intensity and duration encourage them to continue Theexample dialogue given for Inactive patients could be prefaced with the followingldquoYou say you do three hours or more of walking per week So that I mightbetter understand how walking fits into your day perhaps you could talk methrough a typical day for you starting from when you get up in the morningright through to when you go to bed telling me where walking fits in Howabout yesterday could you talk me through yesterdayrdquoIf the patient insists the previous day was atypical use the day before that Try toavoid going too far back as the accuracy of recall will be diminished Thepractitionerrsquos task in this exercise is simply to listen without offering any judgementof what is being said This is not further assessment of the patientrsquos activity The aimis to get the patient talking about their current behaviour in a non-threatening (thethreat of being told to change) environment that will build rapport and conveys to thepatient that the practitioner listens and is genuinely interested in their situationEnsure you assess the level of intensity of walking you can use the following tool toassess intensity0 breathing easily conversation is easy1 breathing lightly and talking easily but heart rate increases2 still talking comfortably but breathing more quickly body warming up3 breathing more deeply and harder talking with a little more difficulty4 breathing very hard and short of breath cannot carry on a conversationLight Activity 0-1 Moderate Activity 2-3 Vigorous Activity 4Patients should be hitting 2-3 for the walking to count towards their activity levelOnce the patient has completed the description of their day the practitioner shouldsimply summarise the information on walking and then proceed to the motivation andconfidence questions described above as appropriate1 7ANNEX 3 GPPAQ TECHNICAL BACKGROUND AND EVALUATIONIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivityThe measure was intended for use in routine general practice and its purpose was toprovide a simple 4-level Physical Activity Index (PAI) reflecting an individualrsquos currentphysical activity The index would be used to decide when interventions to increase

physical activity might be appropriate A working title for the measure was theGeneral Practice Physical Activity Questionnaire (GPPAQ)After reviewing the literature and consultation with experts performancerequirements for the GPPAQ were agreed These were thatbull The method of completion should be self explanatorybull It should be designed for use by adults aged 18-74 years (later revised to 16-74 years)bull It should be possible for respondents to complete the questionnaire withoutassistancebull It should take less than one minute to completebull Individual physical activity categories should be simple requiring limitedcomputationbull The physical activity categories should allow for the assignment of a physicalactivity Read Codebull The output of the questionnaire should enable practice staff to make adecision on whether the patient concerned should be advised to be moreactive or whether more detailed assessment was requiredAlthough no existing self-report measure of physical activity had specifically beendeveloped for routine general practice a short physical activity questionnaire used inthe European Prospective Investigation into Cancer (EPIC) met many of the criteriaand a simple index of physical activity could be derived It had establishedacceptable levels of repeatability and validity in a sample of English adults aged 40-65 years (Wareham et al 2002) It was decided that this short questionnaire shouldform the basis of the new measureA pilot study was conducted in three general practices with practice nursesadministering the self-completion of GPPAQ to 61 patients from a variety of newlyregistered patients including a number of patients for whom English was not the firstlanguage The GPPAQ was well received by nurses patients and generalpractitioners Practitioners welcomed a simple and efficient way of assessingphysical activity In particular they were keen to have a standardised way ofassigning Read Codes for physical activity The patients did not experience anyproblems in completing the questionnaire even when English was not the firstlanguageThe pilot study was limited to new registration appointments but most practitionerssuggested other possible uses for the GPPAQ including hypertension and diabetesclinics1 8Due to the positive findings of the pilot study a further study was conducted toexamine how reliable and accurate the GPPAQ was in routine general practice Foursurgeries were recruited in Coventry West Midlands Table 2 summarises thesurgeriesTable 2 Summary of study surgeriesPractice 1RegisteredpatientsNumberof GPsPatientCharacteristics1 10600 6

Mixed income70 white2 - -Low incomeMainly white3 11500 6Middle incomeMainly white4 - -Low income50 white5 14400 9Mixed income70 white6 6450 3Mixed incomeMainly whiteNB Practices 1 and 2 have two locations as do Practices 3 and 4

A Research Fellow (RF) of the University of Warwick recruited patients in the waitingrooms of the four surgeries The timing of recruiting visits to the surgeries wasvaried The routine nature of the recruitment meant that study participants werethose who normally attend general practice A total of 334 participants successfullycompleted the GPPAQ and a total of 258 participants completed it again a weeklater The PAI category allocated to each individual resulting from the completion ofthe second GPPAQ was compared with allocation to a physical activity categoryresulting from analysis of activity recorded for the same individual during thepreceding week using an Actigraph motion sensor Demographic characteristics ofparticipants who completed the first GPPAQ are summarised in Table 2Table 3 Participant characteristicsN GenderMaleFemale109223328672Age group18-2425-3435-4445-5455-6465-74226167746543

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

Pathway that uses the GPPAQ to screen patients for inactivity and then offers a BriefIntervention based on the principles of Motivational Interviewing to assist behaviourchange to all those classified as less than activeThe NICE guidance states that if (through validated screening tool such as GPPAQ)an individual is identified as less than active practitioners should offer a briefintervention in physical activity Which should include the followingrecommendations1048707 When providing physical activity advice primary care practitioners should takeinto account the individualrsquos needs preferences and circumstances1048707 They should agree goals with them They should also provide writteninformation about the benefits of activity and the local opportunities to beactive1048707 Where appropriate offer a referral into a condition specific or exercise onreferral programme if they exist in your area1048707 They should follow them up at appropriate intervals over a 3 to 6 monthperiod1048707 For those with CHD risk of greater than 30 over ten years GPPAQ shouldbe completed annuallyThe patients defined as lsquoActiversquo should receive a degree of verbal reinforcement thatreflects their current level of physical activity and should be encouraged to eithermake small increases to their physical activity or continue with their current levelFor those who are classified as ldquoless than activerdquo through the GPPAQ but say thatthey walk further investigation is required into the frequency and intensity If thepractitioner deems the patient sufficiently active protocol for an ldquoactiverdquo patient canfollow If unsure in any way or a patient expresses an interest in increasing theirphysical activity levels a brief intervention can be givenThe GPPAQ is also appropriate for use in the NHS Health Check programme whichwill assess peoplersquos risk of heart disease stroke kidney disease and diabetes andsupport people to reduce or manage that risk through individually tailored advice Ifthrough GPPAQ the individual is identified as less than active practitioners shouldoffer a brief intervention in physical activity

2 THE CASE FOR PHYSICAL ACTIVITY FOR HEALTHThe Chief Medical Officerrsquos report At least five a week published in 2004 set outthe important general health benefits associated with physical activity These werereflected in the recently published Be Active Be Healthy (2009) ndash A plan to get thenation movingPhysical activity can help all of us to lead healthier and even happier livesirrespective of age Even relatively small increases in physical activity areassociated with some protection against chronic disease and improved quality of lifeThe health benefits of physical activity are significant and well recognised Regularphysical activity of moderate intensity such as brisk walking can bring about majorhealth benefits as well as significant cost savings for the NHS Increasing levels ofphysical activity would contribute to achieving reductions in coronary heart diseaseand obesity hypertension depression and anxietyPeople who are physically active reduce their risk of developing major chronicdiseases ndash such as coronary heart disease stroke and type 2 diabetes ndash by up to50 and the risk of premature death by about 20ndash30Physical activity

bull is associated with a reduction in the overall risk of cancer has a clearprotective effect on colon cancer and is associated with a reduced risk ofbreast cancer in women after the menopausebull reduces the risk of diabetes ndash physically active people have a 33ndash50 lowerrisk of developing type 2 diabetes compared with inactive people with aparticularly strong preventive effect for those at high risk of developingdiabetesbull is important for helping people to maintain weight loss over several months oryears (Those who include physical activity as part of their weight loss planhave a better chance of long-term success Physical activity brings importantreductions in risk of mortality and morbidity for those who are alreadyoverweight or obese)bull can help protect against osteoporosis and have beneficial effects in those withosteoarthritis and low back painbull in childhood has a range of benefits including healthy growth anddevelopment maintenance of energy balance psychological well-being andsocial interaction and bull is associated with reduced risk of depression anddementia in later life is effective in the treatment of clinical depression andcan be as successful as psychotherapy or medication particularly in thelonger termMore generally physical activity helps people feel better and feel better aboutthemselves as well as helping to reduce physiological reactions to stress Thebenefits though can go well beyond our own health and well-being With highertransport costs and concerns about global warming more cycling and walking as5part of daily life can save money and help the environment Fewer car journeys canreduce traffic congestion and pollution feeding back into the health of communitiesPhysical activity also offers us opportunities for more social interaction ndash whether it isby joining a walking group being part of a team engaging in sport or simply leavingthe car at home for short local tripsA CHEIF MEDICAL OFFICER RECOMMENDATIONS FOR PHYSICAL ACTIVITYRecommendations for active living throughout the lifecourseFor general health benefits adults should achieve a total of at least 30 minutes a dayof at least moderate intensity physical activity on 5 or more days of the weekThe recommendations for adults are also appropriate for older adults Older peopleshould take particular care to keep moving and retain their mobility through dailyactivity Additionally specific activities that promote improved strength co-ordinationand balance are particularly beneficial for older peopleThe recommended levels of activity can be achieved either by doing all the dailyactivity in one session or through several shorter bouts of activity of 10 minutes ormore The activity can be lifestyle activity or structured exercise or sport or acombination of theseLifestyle activity means activities that are performed as part of everyday life such as climbing stairsor brisk walkingB CURRENT PHYSICAL ACTIVITY LEVELSCurrently 40 of men and 28 of women meet the Chief Medical Officerrsquosrecommendations for physical activity This represents an increase from levelsrecorded in 1997 (32 and 21 respectively) Health Survey for England 2007

Participation in physical activity declines significantly with age for both sexes whilethe prevalence of those achieving less than 30 minutes of at least moderate intensityactivity increases with age and is markedly higher in some groups Only 17 of menand 13 of women between the ages of 65 and 74 meet the Chief Medical Officerrsquosrecommendation for physical activity This drops to 8 and 3 of men and womenrespectively over the age of 75Levels of physical activity also show an association with ethnicity With the exceptionof Black Caribbean and Irish populations all other minority ethnic groups have lowerrates of adherence to the Chief Medical Officerrsquos recommendations on physicalactivity for adults Inequalities are greatest for South Asian women Only 11 ofBangladeshi and 14 of Pakistani women were reported to have done therecommended amounts of physical activity compared with 25 in the generalpopulationThe Public Health White Paper Choosing health Making healthier choices easierreiterated the commitment to develop a patient activity questionnaire to support NHSstaff and others to understand their patientsrsquo levels of physical activity63 THE GPPAQ SCREENING TOOLA BACKGROUNDIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivity which could be used in routine general practice to assist Primary CareTrusts to meet the National Service Framework recommendations that primary careteams assess and record the modifiable risk factors for each of their patientsincluding physical activityThis questionnaire is called the GP Physical Activity Questionnaire and wasvalidated for patients aged 16-74 as a screening tool for physical activity levels inprimary careB INTENDED PURPOSEThe General Practice Physical Activity Questionnaire (GPPAQ) is a validatedscreening tool that1048707 Is used to assess adult (16 ndash 74 years) physical activity levels1048707 Provides a simple 4-level Physical Activity Index (PAI) of Active ModeratelyActive Moderately Inactive and Inactive That is correlated to CVD risk1048707 Is used to help inform a practitioner of when a brief intervention to increasephysical activity is appropriate All patients who receive a score less than Activeshould be offered a Brief Intervention in Physical Activity (NICE Guidance 2006)1048707 Is a useful screening tool for the Vascular Risk Health Checks programmeAlthough the questionnaire includes walking DIY green exercise and houseworkthese are not reflected in the final score due to significant over reporting observedduring validation and further questioning of walking amount and walking intensity isrequired in order to confirm the need for a brief intervention Details of how to probethe walking question are set out in annex 2The GPPAQ is appropriate for use in the NHS Health Check programme which willassess peoplersquos risk of heart disease stroke kidney disease and diabetes andsupport people to reduce or manage that risk through individually tailored advice Ifthrough GPPAQ the individual is identified as less than active practitioners shouldoffer a brief intervention in physical activityC TOOLS FOR PRACTICAL USE IN PRIMARY CAREThe General Practice Physical Activity Questionnaire comprises

bull A written questionnaire for completion by patients if completed outside of theconsultationbull Electronic template of the questionnaire (Excel) which can be completed duringthe consultation and automatically generates the Physical Activity Index (PAI)bull Coding algorithm (See Appendix 1)bull Read Codes for the PAI which can be used in patient record templatesThe DH is planning to incorporate the GPPAQ algorithm within patient recordsoftware it is currently only available through bolt on package frontdesk Until then7the electronic template of the questionnaire can be saved as a separate file for eachpatientPlease note that the coding algorithm is an integral part of the questionnaireAny unauthorised modification to the coding algorithm is likely to negate thevalidation of the questionnaireThere are specific read codes for the Physical Activity Index which can be integratedinto locally created templates within patient recordsThe GPPAQ algorithm classifies patients into one of four categories physicalactivity indexes ndash active moderately active moderately inactive inactiveMore detail is available in Annex 184 INSTRUCTIONS FOR USE IN PRIMARY CAREA HOW OFTEN TO USEThe level of physical activity should be entered on the clinical record for all patientsover the age of sixteen and should be updated at least every five years1For patients with clinical evidence of occlusive arterial disease and those whose riskof CHD events is greater than 30 over ten years physical activity levels should berecorded annuallyB EXCLUSIONS FOR USEThe GPPAQ was not evaluated for use in children and young people (aged lt16years) or adults older than 74 years Both groups may require age-specific physicalactivity assessmentsThe GPPAQ has not been designed for use as a research tool to measure selfreportedphysical activity before and after interventions and therefore is notappropriate for measuring the effectiveness of physical activity interventionsC COMPLETING THE QUESTIONNAIREThe General Practice Physical Activity Questionnaire takes approximately 30seconds to fill inGPPAQ can be completed1048707 By patients waiting for appointments1048707 In disease specific clinics1048707 In routine consultations1048707 In activity clinicsIt then takes a maximum of 1-2 minutes to transfer the responses to the electronictemplate and analyse the result The template will automatically assign a PhysicalActivity IndexD ANALYSING THE PHYSICAL ACTIVITY INDEX (PAI)Questions concerning walking houseworkchildcare and gardeningDIY are includedHowever they have not been shown to yield data of a sufficient reliability tocontribute to an objective assessment of overall physical activity levels and are notincluded in the calculation of the PAI

Where patients have reported that they walk regularly and their PAI is less thanactive a discussion is needed around the amount of and intensity of walking Thiswill help to determine whether the patient is currently meeting the Chief MedicalOfficerrsquos recommendation for 30 minutes of moderate activity on 5 days of the week(or more)1 Department of Health (2000) National Service Framework for CoronaryHeart Disease London Department of Health Chapter 2 Appendix A9Walking Gardening (Green exercise) Housework DIY activities can contribute tomeeting the Chief Medical Officerrsquos recommendation and walking in particularshould be encouragedAll patients who receive a score of less than active should be offered a BriefIntervention in Physical Activity in line with the NICE Guidance (2006)1 05 NICE PUBLIC HEALTH GUIDANCE FOUR COMMONLY USED METHODS TOINCREASE PHYSICAL ACTIVITY BRIEF INTERVENTIONSA BRIEF INTERVENTION IN PHYSICAL ACTIVITYNICE Public Health Intervention Guidance published in March 2006 endorsed BriefInterventions in Physical ActivityThe recommendations stipulated that primary care practitioners should1048707 Take the opportunity whenever possible to identify inactive adults1048707 Advise them to aim for 30 minutes of moderate activity on 5 days of the week(or more)1048707 Use their judgement to determine when this would be inappropriate (forexample because of medical conditions or personal circumstances)1048707 Use a validated tool such as the Department of Healthrsquos general practitionerphysical activity questionnaire (GPPAQ) to identify inactive individualsThe group with most to gain from an increase in physical activity are those with a PAIof 1 ie the lsquoInactiversquo It is estimated that 9 of CHD could be avoided if all thosewho are sedentary and moderately inactive became more moderately activehttpwwwniceorgukGuidancePH2GuidancepdfEnglishKey pointsIf through the validated tool GPPAQ the individual is identified as less than activepractitioners should offer a brief intervention in physical activity1048707 When providing physical activity advice primary care practitioners should takeinto account the individualrsquos needs preferences and circumstances1048707 They should agree goals with them They should also provide writteninformation about the benefits of activity and the local opportunities to beactive1048707 Where appropriate offer a referral into a condition specific or exercise onreferral programme if they are available locally1048707 They should follow them up at appropriate intervals over a 3 to 6 monthperiod1048707 Those with CHD risk of greater than 30 over ten years GPPAQ should becompleted annuallyThe lsquoActiversquo group should receive a degree of verbal reinforcement that reflects theircurrent level of physical activity and should be encouraged to either make smallincreases or continue with their current physical activity levelFor those who are classified as ldquoless than activerdquo through the GPPAQ but say thatthey walk further investigation is required into the frequency and intensity If the

practitioner deems the patient sufficiently active protocol for an ldquoactiverdquo patient canfollow For those who are still deemed inactive or unsure if they meet the CMOrecommendations or if a patient still expresses interest in increasing their physicalactivity levels a brief intervention can be given For details about how to discusswalking in greater detail please see Annex 21 1B PHYSICAL ACTIVITY CARE PATHWAYThe Department of Health has developed a Physical Activity Care Pathway to helpprimary care deliver the NICE Guidance for Brief InterventionsThis1048707 Uses the GPPAQ to screen patients for inactivity1048707 Follows the NICE guidance protocols detailed above to deliver a briefintervention including patient follow up at 36 and 12 months1048707 Uses the evidence based behaviour change technique MotivationalInterviewing to deliver the brief interventionThe Physical Activity Care Pathway has been positively evaluated by the BritishHeart Foundation National Centre for Physical Activity and Health at LoughboroughUniversity in a feasibility study in 14 surgeries that concluded in September 2008The Department of Health plans to launch the Physical Activity Care Pathwayresources in late 2009 This will include a commissioning toolkit and how to guide atraining package and patient resource pack1 2ANNEX 1A CALCULATING THE 4-LEVEL PHYSICAL ACTIVITY INDEX (PAI)Patients can be classified into four categories based on the original EPIC index fromwhich the GPPAQ was developedInactive Sedentary job and no physical exercise or cyclingModerately inactive Sedentary job and some but lt 1 hour physical exercise and orcycling per week ORStanding job and no physical exercise or cyclingModerately active Sedentary job and 1-29 hours physical exercise and or cyclingper week ORStanding job and some but lt 1 hour physical exercise and orcycling per week ORPhysical job and no physical exercise or cyclingActive Sedentary job and ge 3 hours physical exercise and or cyclingper week ORStanding job and 1-29 hours physical exercise and or cyclingper week ORPhysical job and some but lt 1 hour physical exercise and orcycling per week ORHeavy manual jobNote Questions concerning Walking HouseworkChildcare and GardeningDIY havebeen included to allow patients to record their physical activity in these categorieshowever these questions have not been shown to yield data of a sufficient reliabilityto contribute to an understanding of overall physical activity levels As noted abovefurther questioning is requiredB SUMMARY OF THE PAIOccupationPhysical exercise and or

cycling (hrwk)Sedentary Standing Physical Heavy Manual0 Inactive ModeratelyInactiveModeratelyActiveActiveSome but lt 1 ModeratelyInactiveModeratelyActiveActive Active1-29 ModeratelyActiveActive Active Activege 3 Active Active Active Active1 3C COMBINING RESPONSES FOR PHYSICAL EXERCISE AND CYCLINGCyclingPhysicalExercise0 Some but lt 1 1-29 ge30 0 Some but lt 1 1-29 ge3Some but lt 1 Some but lt 1 1-29 ge3 ge31-29 1-29 ge3 ge3 ge3ge3 ge3 ge3 ge3 ge3D GPPAQ READ CODES4 Byte Version 2 CTV3138X | GPPAQphyscl act indinactive138X | Generalpractice physicalactivity questionnairephysical activityindex inactiveXaPP8 | General practicephysical activityquestionnaire physicalactivity index inactive366121000000108 | General practicephysical activity questionnaire physicalactivity index inactive (finding)138Y | GPPAQphys act ind modinactv138Y | Generalpractice physicalactivity questionnairephysical activityindex moderatelyinactiveXaPPB | General practicephysical activityquestionnaire physicalactivity index moderately

inactive366171000000107 | General practicephysical activity questionnaire physicalactivity index moderately inactive(finding)138a | GPPAQphys act ind modactive138a | Generalpractice physicalactivity questionnairephysical activityindex moderatelyactiveXaPPD | General practicephysical activityquestionnaire physicalactivity index moderatelyactive366211000000105 | General practicephysical activity questionnaire physicalactivity index moderately active(finding)138b | GPPAQphysical act indactive138b | Generalpractice physicalactivity questionnairephysical activityindex activeXaPPE | General practicephysical activityquestionnaire physicalactivity index active366241000000106 | General practicephysical activity questionnaire physicalactivity index active (finding)1 4ANNEX 2A AN EXAMPLE OF A MOTIVATIONAL INTERVIEW WITHIN APHYSICAL ACTIVITY BRIEF INTERVENTIONPractitioners can consider the following example of a brief verbal intervention forInactive patients based on the principles of Motivational Interviewing (MI)Any intervention should be consistent with the agenda on patient led consultations andchoice One way to do this is to base behaviour-change negotiations on the principles ofmotivational interviewing (MI) Although developed in the field of addictions brief versions ofMI have been adapted and applied to a wide variety of behaviours and conditions such assmoking diet physical activity medical adherence and diabetes with evidence ofeffectiveness (Resnicow et al 2002 Rollnick 1999 Rubak 2005)Motivational Interviewing elicits change talk in the patient empowering them tochange their own behaviour Below are example questions for an MI based dialogueExample Dialogue for Inactive PatientsQuestion set OneldquoOn a scale from 0 to 10 where 0 is not important at all and 10 is extremely

important how important is getting more active for yourdquoldquoWhy did you pick this numberldquoldquoWhy did you not pick a lower numberldquoldquoWhat would you need to do to get you to a higher numberrdquoQuestion set TwoldquoNow think about why you want to do this Think about how yoursquoll feel whatyoursquoll look like what yoursquoll be able to do that you canrsquot do now Also thinkabout what might be stopping you from changing and what will happen if youdonrsquotrdquoWhy you want to changeeg To be able to play with children grandchildren To help healthWhat will happen if you changeeg more energy less lonely control conditionWhy you donrsquot want to changeeg low confidence donrsquot think will enjoy itWhat will happen if you donrsquoteg condition will get worse feel bad about self not be able to play withchildrengrandchildrenQuestion set ThreelsquoIf you were to decide to increase your physical activity how confident areyou that you would succeed If on a scale of 0 to 10 0 means that you are1 5not at all confident and 10 means that you are 100 confident you couldbecome more active What number would you give yourselfrdquoWhy did you pick this number on the scaleWhy did you not pick a lower numberWhat would you need to do to get a higher numberAll the while yoursquore trying elicit change talk from them and reaffirm these statementsback to the patientFinally provide the patient with a brief summary of what you heard and then askldquoWhat do you think the next step is for yourdquoYou can talk about the patients day and work with the patient about when activitycould be built in eg getting off the bus a stop early or walking children to schoolAnd also talk about activities that might be of interest to the patient whether itrsquosgardening dance swimming cycling walking or footballA common response is for the patient to say they donrsquot know or are uncertain If theydo follow withldquoLetrsquos list what the options are at the moment You couldStay as you are and do nothingStart to increase the amount of physical activity that you dordquoAgain this should illicit change talkGo through the patients day with them and talk about when activity could bebuilt in eg getting off the bus a stop early joining in a health walk or walkingthe children to schoolAlso talk about what activities might be of interest to them signpost to localactivities from gardening to dance to footballAsk the patient what they make of these opportunitiesIf interested talk to the patient about appropriate levels of activity and how tobuild up their activity levels If someone hasnrsquot been active for a long timegoing straight into vigorous activity isnrsquot a good idea advise patients to build

up their activity levels and intensity graduallyEncourage a patient to set a specific goal such asldquoI will go for a walk on Tuesday at lunchtime at the park for thirty minutes If Icanrsquot make it then I will go on WednesdayrdquoIn just a few minutes it is possible to encourage the patient to consider why and howthey might change their physical activity without feeling as if they are being pushedor coerced into something they are not ready for(Dialogue based on Rollnick et al 1997 Miller 2005 Rollnick et al 2005)1 6B ASSESSING INACTIVE PATIENTS WHO SELF REPORT 3 HOURSOR MORE PER WEEK OF WALKINGPatients who fall within the inactive category but claim to undertake significantamounts of walking may require a modified brief intervention that probes theirunderstanding of walking and walking pace and the basis upon which they havedeclared the amount of walking accumulated during the last week For those patientswho remain confident that they achieve the recommended levels of physical activityby virtue of their walking intensity and duration encourage them to continue Theexample dialogue given for Inactive patients could be prefaced with the followingldquoYou say you do three hours or more of walking per week So that I mightbetter understand how walking fits into your day perhaps you could talk methrough a typical day for you starting from when you get up in the morningright through to when you go to bed telling me where walking fits in Howabout yesterday could you talk me through yesterdayrdquoIf the patient insists the previous day was atypical use the day before that Try toavoid going too far back as the accuracy of recall will be diminished Thepractitionerrsquos task in this exercise is simply to listen without offering any judgementof what is being said This is not further assessment of the patientrsquos activity The aimis to get the patient talking about their current behaviour in a non-threatening (thethreat of being told to change) environment that will build rapport and conveys to thepatient that the practitioner listens and is genuinely interested in their situationEnsure you assess the level of intensity of walking you can use the following tool toassess intensity0 breathing easily conversation is easy1 breathing lightly and talking easily but heart rate increases2 still talking comfortably but breathing more quickly body warming up3 breathing more deeply and harder talking with a little more difficulty4 breathing very hard and short of breath cannot carry on a conversationLight Activity 0-1 Moderate Activity 2-3 Vigorous Activity 4Patients should be hitting 2-3 for the walking to count towards their activity levelOnce the patient has completed the description of their day the practitioner shouldsimply summarise the information on walking and then proceed to the motivation andconfidence questions described above as appropriate1 7ANNEX 3 GPPAQ TECHNICAL BACKGROUND AND EVALUATIONIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivityThe measure was intended for use in routine general practice and its purpose was toprovide a simple 4-level Physical Activity Index (PAI) reflecting an individualrsquos currentphysical activity The index would be used to decide when interventions to increase

physical activity might be appropriate A working title for the measure was theGeneral Practice Physical Activity Questionnaire (GPPAQ)After reviewing the literature and consultation with experts performancerequirements for the GPPAQ were agreed These were thatbull The method of completion should be self explanatorybull It should be designed for use by adults aged 18-74 years (later revised to 16-74 years)bull It should be possible for respondents to complete the questionnaire withoutassistancebull It should take less than one minute to completebull Individual physical activity categories should be simple requiring limitedcomputationbull The physical activity categories should allow for the assignment of a physicalactivity Read Codebull The output of the questionnaire should enable practice staff to make adecision on whether the patient concerned should be advised to be moreactive or whether more detailed assessment was requiredAlthough no existing self-report measure of physical activity had specifically beendeveloped for routine general practice a short physical activity questionnaire used inthe European Prospective Investigation into Cancer (EPIC) met many of the criteriaand a simple index of physical activity could be derived It had establishedacceptable levels of repeatability and validity in a sample of English adults aged 40-65 years (Wareham et al 2002) It was decided that this short questionnaire shouldform the basis of the new measureA pilot study was conducted in three general practices with practice nursesadministering the self-completion of GPPAQ to 61 patients from a variety of newlyregistered patients including a number of patients for whom English was not the firstlanguage The GPPAQ was well received by nurses patients and generalpractitioners Practitioners welcomed a simple and efficient way of assessingphysical activity In particular they were keen to have a standardised way ofassigning Read Codes for physical activity The patients did not experience anyproblems in completing the questionnaire even when English was not the firstlanguageThe pilot study was limited to new registration appointments but most practitionerssuggested other possible uses for the GPPAQ including hypertension and diabetesclinics1 8Due to the positive findings of the pilot study a further study was conducted toexamine how reliable and accurate the GPPAQ was in routine general practice Foursurgeries were recruited in Coventry West Midlands Table 2 summarises thesurgeriesTable 2 Summary of study surgeriesPractice 1RegisteredpatientsNumberof GPsPatientCharacteristics1 10600 6

Mixed income70 white2 - -Low incomeMainly white3 11500 6Middle incomeMainly white4 - -Low income50 white5 14400 9Mixed income70 white6 6450 3Mixed incomeMainly whiteNB Practices 1 and 2 have two locations as do Practices 3 and 4

A Research Fellow (RF) of the University of Warwick recruited patients in the waitingrooms of the four surgeries The timing of recruiting visits to the surgeries wasvaried The routine nature of the recruitment meant that study participants werethose who normally attend general practice A total of 334 participants successfullycompleted the GPPAQ and a total of 258 participants completed it again a weeklater The PAI category allocated to each individual resulting from the completion ofthe second GPPAQ was compared with allocation to a physical activity categoryresulting from analysis of activity recorded for the same individual during thepreceding week using an Actigraph motion sensor Demographic characteristics ofparticipants who completed the first GPPAQ are summarised in Table 2Table 3 Participant characteristicsN GenderMaleFemale109223328672Age group18-2425-3435-4445-5455-6465-74226167746543

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

bull is associated with a reduction in the overall risk of cancer has a clearprotective effect on colon cancer and is associated with a reduced risk ofbreast cancer in women after the menopausebull reduces the risk of diabetes ndash physically active people have a 33ndash50 lowerrisk of developing type 2 diabetes compared with inactive people with aparticularly strong preventive effect for those at high risk of developingdiabetesbull is important for helping people to maintain weight loss over several months oryears (Those who include physical activity as part of their weight loss planhave a better chance of long-term success Physical activity brings importantreductions in risk of mortality and morbidity for those who are alreadyoverweight or obese)bull can help protect against osteoporosis and have beneficial effects in those withosteoarthritis and low back painbull in childhood has a range of benefits including healthy growth anddevelopment maintenance of energy balance psychological well-being andsocial interaction and bull is associated with reduced risk of depression anddementia in later life is effective in the treatment of clinical depression andcan be as successful as psychotherapy or medication particularly in thelonger termMore generally physical activity helps people feel better and feel better aboutthemselves as well as helping to reduce physiological reactions to stress Thebenefits though can go well beyond our own health and well-being With highertransport costs and concerns about global warming more cycling and walking as5part of daily life can save money and help the environment Fewer car journeys canreduce traffic congestion and pollution feeding back into the health of communitiesPhysical activity also offers us opportunities for more social interaction ndash whether it isby joining a walking group being part of a team engaging in sport or simply leavingthe car at home for short local tripsA CHEIF MEDICAL OFFICER RECOMMENDATIONS FOR PHYSICAL ACTIVITYRecommendations for active living throughout the lifecourseFor general health benefits adults should achieve a total of at least 30 minutes a dayof at least moderate intensity physical activity on 5 or more days of the weekThe recommendations for adults are also appropriate for older adults Older peopleshould take particular care to keep moving and retain their mobility through dailyactivity Additionally specific activities that promote improved strength co-ordinationand balance are particularly beneficial for older peopleThe recommended levels of activity can be achieved either by doing all the dailyactivity in one session or through several shorter bouts of activity of 10 minutes ormore The activity can be lifestyle activity or structured exercise or sport or acombination of theseLifestyle activity means activities that are performed as part of everyday life such as climbing stairsor brisk walkingB CURRENT PHYSICAL ACTIVITY LEVELSCurrently 40 of men and 28 of women meet the Chief Medical Officerrsquosrecommendations for physical activity This represents an increase from levelsrecorded in 1997 (32 and 21 respectively) Health Survey for England 2007

Participation in physical activity declines significantly with age for both sexes whilethe prevalence of those achieving less than 30 minutes of at least moderate intensityactivity increases with age and is markedly higher in some groups Only 17 of menand 13 of women between the ages of 65 and 74 meet the Chief Medical Officerrsquosrecommendation for physical activity This drops to 8 and 3 of men and womenrespectively over the age of 75Levels of physical activity also show an association with ethnicity With the exceptionof Black Caribbean and Irish populations all other minority ethnic groups have lowerrates of adherence to the Chief Medical Officerrsquos recommendations on physicalactivity for adults Inequalities are greatest for South Asian women Only 11 ofBangladeshi and 14 of Pakistani women were reported to have done therecommended amounts of physical activity compared with 25 in the generalpopulationThe Public Health White Paper Choosing health Making healthier choices easierreiterated the commitment to develop a patient activity questionnaire to support NHSstaff and others to understand their patientsrsquo levels of physical activity63 THE GPPAQ SCREENING TOOLA BACKGROUNDIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivity which could be used in routine general practice to assist Primary CareTrusts to meet the National Service Framework recommendations that primary careteams assess and record the modifiable risk factors for each of their patientsincluding physical activityThis questionnaire is called the GP Physical Activity Questionnaire and wasvalidated for patients aged 16-74 as a screening tool for physical activity levels inprimary careB INTENDED PURPOSEThe General Practice Physical Activity Questionnaire (GPPAQ) is a validatedscreening tool that1048707 Is used to assess adult (16 ndash 74 years) physical activity levels1048707 Provides a simple 4-level Physical Activity Index (PAI) of Active ModeratelyActive Moderately Inactive and Inactive That is correlated to CVD risk1048707 Is used to help inform a practitioner of when a brief intervention to increasephysical activity is appropriate All patients who receive a score less than Activeshould be offered a Brief Intervention in Physical Activity (NICE Guidance 2006)1048707 Is a useful screening tool for the Vascular Risk Health Checks programmeAlthough the questionnaire includes walking DIY green exercise and houseworkthese are not reflected in the final score due to significant over reporting observedduring validation and further questioning of walking amount and walking intensity isrequired in order to confirm the need for a brief intervention Details of how to probethe walking question are set out in annex 2The GPPAQ is appropriate for use in the NHS Health Check programme which willassess peoplersquos risk of heart disease stroke kidney disease and diabetes andsupport people to reduce or manage that risk through individually tailored advice Ifthrough GPPAQ the individual is identified as less than active practitioners shouldoffer a brief intervention in physical activityC TOOLS FOR PRACTICAL USE IN PRIMARY CAREThe General Practice Physical Activity Questionnaire comprises

bull A written questionnaire for completion by patients if completed outside of theconsultationbull Electronic template of the questionnaire (Excel) which can be completed duringthe consultation and automatically generates the Physical Activity Index (PAI)bull Coding algorithm (See Appendix 1)bull Read Codes for the PAI which can be used in patient record templatesThe DH is planning to incorporate the GPPAQ algorithm within patient recordsoftware it is currently only available through bolt on package frontdesk Until then7the electronic template of the questionnaire can be saved as a separate file for eachpatientPlease note that the coding algorithm is an integral part of the questionnaireAny unauthorised modification to the coding algorithm is likely to negate thevalidation of the questionnaireThere are specific read codes for the Physical Activity Index which can be integratedinto locally created templates within patient recordsThe GPPAQ algorithm classifies patients into one of four categories physicalactivity indexes ndash active moderately active moderately inactive inactiveMore detail is available in Annex 184 INSTRUCTIONS FOR USE IN PRIMARY CAREA HOW OFTEN TO USEThe level of physical activity should be entered on the clinical record for all patientsover the age of sixteen and should be updated at least every five years1For patients with clinical evidence of occlusive arterial disease and those whose riskof CHD events is greater than 30 over ten years physical activity levels should berecorded annuallyB EXCLUSIONS FOR USEThe GPPAQ was not evaluated for use in children and young people (aged lt16years) or adults older than 74 years Both groups may require age-specific physicalactivity assessmentsThe GPPAQ has not been designed for use as a research tool to measure selfreportedphysical activity before and after interventions and therefore is notappropriate for measuring the effectiveness of physical activity interventionsC COMPLETING THE QUESTIONNAIREThe General Practice Physical Activity Questionnaire takes approximately 30seconds to fill inGPPAQ can be completed1048707 By patients waiting for appointments1048707 In disease specific clinics1048707 In routine consultations1048707 In activity clinicsIt then takes a maximum of 1-2 minutes to transfer the responses to the electronictemplate and analyse the result The template will automatically assign a PhysicalActivity IndexD ANALYSING THE PHYSICAL ACTIVITY INDEX (PAI)Questions concerning walking houseworkchildcare and gardeningDIY are includedHowever they have not been shown to yield data of a sufficient reliability tocontribute to an objective assessment of overall physical activity levels and are notincluded in the calculation of the PAI

Where patients have reported that they walk regularly and their PAI is less thanactive a discussion is needed around the amount of and intensity of walking Thiswill help to determine whether the patient is currently meeting the Chief MedicalOfficerrsquos recommendation for 30 minutes of moderate activity on 5 days of the week(or more)1 Department of Health (2000) National Service Framework for CoronaryHeart Disease London Department of Health Chapter 2 Appendix A9Walking Gardening (Green exercise) Housework DIY activities can contribute tomeeting the Chief Medical Officerrsquos recommendation and walking in particularshould be encouragedAll patients who receive a score of less than active should be offered a BriefIntervention in Physical Activity in line with the NICE Guidance (2006)1 05 NICE PUBLIC HEALTH GUIDANCE FOUR COMMONLY USED METHODS TOINCREASE PHYSICAL ACTIVITY BRIEF INTERVENTIONSA BRIEF INTERVENTION IN PHYSICAL ACTIVITYNICE Public Health Intervention Guidance published in March 2006 endorsed BriefInterventions in Physical ActivityThe recommendations stipulated that primary care practitioners should1048707 Take the opportunity whenever possible to identify inactive adults1048707 Advise them to aim for 30 minutes of moderate activity on 5 days of the week(or more)1048707 Use their judgement to determine when this would be inappropriate (forexample because of medical conditions or personal circumstances)1048707 Use a validated tool such as the Department of Healthrsquos general practitionerphysical activity questionnaire (GPPAQ) to identify inactive individualsThe group with most to gain from an increase in physical activity are those with a PAIof 1 ie the lsquoInactiversquo It is estimated that 9 of CHD could be avoided if all thosewho are sedentary and moderately inactive became more moderately activehttpwwwniceorgukGuidancePH2GuidancepdfEnglishKey pointsIf through the validated tool GPPAQ the individual is identified as less than activepractitioners should offer a brief intervention in physical activity1048707 When providing physical activity advice primary care practitioners should takeinto account the individualrsquos needs preferences and circumstances1048707 They should agree goals with them They should also provide writteninformation about the benefits of activity and the local opportunities to beactive1048707 Where appropriate offer a referral into a condition specific or exercise onreferral programme if they are available locally1048707 They should follow them up at appropriate intervals over a 3 to 6 monthperiod1048707 Those with CHD risk of greater than 30 over ten years GPPAQ should becompleted annuallyThe lsquoActiversquo group should receive a degree of verbal reinforcement that reflects theircurrent level of physical activity and should be encouraged to either make smallincreases or continue with their current physical activity levelFor those who are classified as ldquoless than activerdquo through the GPPAQ but say thatthey walk further investigation is required into the frequency and intensity If the

practitioner deems the patient sufficiently active protocol for an ldquoactiverdquo patient canfollow For those who are still deemed inactive or unsure if they meet the CMOrecommendations or if a patient still expresses interest in increasing their physicalactivity levels a brief intervention can be given For details about how to discusswalking in greater detail please see Annex 21 1B PHYSICAL ACTIVITY CARE PATHWAYThe Department of Health has developed a Physical Activity Care Pathway to helpprimary care deliver the NICE Guidance for Brief InterventionsThis1048707 Uses the GPPAQ to screen patients for inactivity1048707 Follows the NICE guidance protocols detailed above to deliver a briefintervention including patient follow up at 36 and 12 months1048707 Uses the evidence based behaviour change technique MotivationalInterviewing to deliver the brief interventionThe Physical Activity Care Pathway has been positively evaluated by the BritishHeart Foundation National Centre for Physical Activity and Health at LoughboroughUniversity in a feasibility study in 14 surgeries that concluded in September 2008The Department of Health plans to launch the Physical Activity Care Pathwayresources in late 2009 This will include a commissioning toolkit and how to guide atraining package and patient resource pack1 2ANNEX 1A CALCULATING THE 4-LEVEL PHYSICAL ACTIVITY INDEX (PAI)Patients can be classified into four categories based on the original EPIC index fromwhich the GPPAQ was developedInactive Sedentary job and no physical exercise or cyclingModerately inactive Sedentary job and some but lt 1 hour physical exercise and orcycling per week ORStanding job and no physical exercise or cyclingModerately active Sedentary job and 1-29 hours physical exercise and or cyclingper week ORStanding job and some but lt 1 hour physical exercise and orcycling per week ORPhysical job and no physical exercise or cyclingActive Sedentary job and ge 3 hours physical exercise and or cyclingper week ORStanding job and 1-29 hours physical exercise and or cyclingper week ORPhysical job and some but lt 1 hour physical exercise and orcycling per week ORHeavy manual jobNote Questions concerning Walking HouseworkChildcare and GardeningDIY havebeen included to allow patients to record their physical activity in these categorieshowever these questions have not been shown to yield data of a sufficient reliabilityto contribute to an understanding of overall physical activity levels As noted abovefurther questioning is requiredB SUMMARY OF THE PAIOccupationPhysical exercise and or

cycling (hrwk)Sedentary Standing Physical Heavy Manual0 Inactive ModeratelyInactiveModeratelyActiveActiveSome but lt 1 ModeratelyInactiveModeratelyActiveActive Active1-29 ModeratelyActiveActive Active Activege 3 Active Active Active Active1 3C COMBINING RESPONSES FOR PHYSICAL EXERCISE AND CYCLINGCyclingPhysicalExercise0 Some but lt 1 1-29 ge30 0 Some but lt 1 1-29 ge3Some but lt 1 Some but lt 1 1-29 ge3 ge31-29 1-29 ge3 ge3 ge3ge3 ge3 ge3 ge3 ge3D GPPAQ READ CODES4 Byte Version 2 CTV3138X | GPPAQphyscl act indinactive138X | Generalpractice physicalactivity questionnairephysical activityindex inactiveXaPP8 | General practicephysical activityquestionnaire physicalactivity index inactive366121000000108 | General practicephysical activity questionnaire physicalactivity index inactive (finding)138Y | GPPAQphys act ind modinactv138Y | Generalpractice physicalactivity questionnairephysical activityindex moderatelyinactiveXaPPB | General practicephysical activityquestionnaire physicalactivity index moderately

inactive366171000000107 | General practicephysical activity questionnaire physicalactivity index moderately inactive(finding)138a | GPPAQphys act ind modactive138a | Generalpractice physicalactivity questionnairephysical activityindex moderatelyactiveXaPPD | General practicephysical activityquestionnaire physicalactivity index moderatelyactive366211000000105 | General practicephysical activity questionnaire physicalactivity index moderately active(finding)138b | GPPAQphysical act indactive138b | Generalpractice physicalactivity questionnairephysical activityindex activeXaPPE | General practicephysical activityquestionnaire physicalactivity index active366241000000106 | General practicephysical activity questionnaire physicalactivity index active (finding)1 4ANNEX 2A AN EXAMPLE OF A MOTIVATIONAL INTERVIEW WITHIN APHYSICAL ACTIVITY BRIEF INTERVENTIONPractitioners can consider the following example of a brief verbal intervention forInactive patients based on the principles of Motivational Interviewing (MI)Any intervention should be consistent with the agenda on patient led consultations andchoice One way to do this is to base behaviour-change negotiations on the principles ofmotivational interviewing (MI) Although developed in the field of addictions brief versions ofMI have been adapted and applied to a wide variety of behaviours and conditions such assmoking diet physical activity medical adherence and diabetes with evidence ofeffectiveness (Resnicow et al 2002 Rollnick 1999 Rubak 2005)Motivational Interviewing elicits change talk in the patient empowering them tochange their own behaviour Below are example questions for an MI based dialogueExample Dialogue for Inactive PatientsQuestion set OneldquoOn a scale from 0 to 10 where 0 is not important at all and 10 is extremely

important how important is getting more active for yourdquoldquoWhy did you pick this numberldquoldquoWhy did you not pick a lower numberldquoldquoWhat would you need to do to get you to a higher numberrdquoQuestion set TwoldquoNow think about why you want to do this Think about how yoursquoll feel whatyoursquoll look like what yoursquoll be able to do that you canrsquot do now Also thinkabout what might be stopping you from changing and what will happen if youdonrsquotrdquoWhy you want to changeeg To be able to play with children grandchildren To help healthWhat will happen if you changeeg more energy less lonely control conditionWhy you donrsquot want to changeeg low confidence donrsquot think will enjoy itWhat will happen if you donrsquoteg condition will get worse feel bad about self not be able to play withchildrengrandchildrenQuestion set ThreelsquoIf you were to decide to increase your physical activity how confident areyou that you would succeed If on a scale of 0 to 10 0 means that you are1 5not at all confident and 10 means that you are 100 confident you couldbecome more active What number would you give yourselfrdquoWhy did you pick this number on the scaleWhy did you not pick a lower numberWhat would you need to do to get a higher numberAll the while yoursquore trying elicit change talk from them and reaffirm these statementsback to the patientFinally provide the patient with a brief summary of what you heard and then askldquoWhat do you think the next step is for yourdquoYou can talk about the patients day and work with the patient about when activitycould be built in eg getting off the bus a stop early or walking children to schoolAnd also talk about activities that might be of interest to the patient whether itrsquosgardening dance swimming cycling walking or footballA common response is for the patient to say they donrsquot know or are uncertain If theydo follow withldquoLetrsquos list what the options are at the moment You couldStay as you are and do nothingStart to increase the amount of physical activity that you dordquoAgain this should illicit change talkGo through the patients day with them and talk about when activity could bebuilt in eg getting off the bus a stop early joining in a health walk or walkingthe children to schoolAlso talk about what activities might be of interest to them signpost to localactivities from gardening to dance to footballAsk the patient what they make of these opportunitiesIf interested talk to the patient about appropriate levels of activity and how tobuild up their activity levels If someone hasnrsquot been active for a long timegoing straight into vigorous activity isnrsquot a good idea advise patients to build

up their activity levels and intensity graduallyEncourage a patient to set a specific goal such asldquoI will go for a walk on Tuesday at lunchtime at the park for thirty minutes If Icanrsquot make it then I will go on WednesdayrdquoIn just a few minutes it is possible to encourage the patient to consider why and howthey might change their physical activity without feeling as if they are being pushedor coerced into something they are not ready for(Dialogue based on Rollnick et al 1997 Miller 2005 Rollnick et al 2005)1 6B ASSESSING INACTIVE PATIENTS WHO SELF REPORT 3 HOURSOR MORE PER WEEK OF WALKINGPatients who fall within the inactive category but claim to undertake significantamounts of walking may require a modified brief intervention that probes theirunderstanding of walking and walking pace and the basis upon which they havedeclared the amount of walking accumulated during the last week For those patientswho remain confident that they achieve the recommended levels of physical activityby virtue of their walking intensity and duration encourage them to continue Theexample dialogue given for Inactive patients could be prefaced with the followingldquoYou say you do three hours or more of walking per week So that I mightbetter understand how walking fits into your day perhaps you could talk methrough a typical day for you starting from when you get up in the morningright through to when you go to bed telling me where walking fits in Howabout yesterday could you talk me through yesterdayrdquoIf the patient insists the previous day was atypical use the day before that Try toavoid going too far back as the accuracy of recall will be diminished Thepractitionerrsquos task in this exercise is simply to listen without offering any judgementof what is being said This is not further assessment of the patientrsquos activity The aimis to get the patient talking about their current behaviour in a non-threatening (thethreat of being told to change) environment that will build rapport and conveys to thepatient that the practitioner listens and is genuinely interested in their situationEnsure you assess the level of intensity of walking you can use the following tool toassess intensity0 breathing easily conversation is easy1 breathing lightly and talking easily but heart rate increases2 still talking comfortably but breathing more quickly body warming up3 breathing more deeply and harder talking with a little more difficulty4 breathing very hard and short of breath cannot carry on a conversationLight Activity 0-1 Moderate Activity 2-3 Vigorous Activity 4Patients should be hitting 2-3 for the walking to count towards their activity levelOnce the patient has completed the description of their day the practitioner shouldsimply summarise the information on walking and then proceed to the motivation andconfidence questions described above as appropriate1 7ANNEX 3 GPPAQ TECHNICAL BACKGROUND AND EVALUATIONIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivityThe measure was intended for use in routine general practice and its purpose was toprovide a simple 4-level Physical Activity Index (PAI) reflecting an individualrsquos currentphysical activity The index would be used to decide when interventions to increase

physical activity might be appropriate A working title for the measure was theGeneral Practice Physical Activity Questionnaire (GPPAQ)After reviewing the literature and consultation with experts performancerequirements for the GPPAQ were agreed These were thatbull The method of completion should be self explanatorybull It should be designed for use by adults aged 18-74 years (later revised to 16-74 years)bull It should be possible for respondents to complete the questionnaire withoutassistancebull It should take less than one minute to completebull Individual physical activity categories should be simple requiring limitedcomputationbull The physical activity categories should allow for the assignment of a physicalactivity Read Codebull The output of the questionnaire should enable practice staff to make adecision on whether the patient concerned should be advised to be moreactive or whether more detailed assessment was requiredAlthough no existing self-report measure of physical activity had specifically beendeveloped for routine general practice a short physical activity questionnaire used inthe European Prospective Investigation into Cancer (EPIC) met many of the criteriaand a simple index of physical activity could be derived It had establishedacceptable levels of repeatability and validity in a sample of English adults aged 40-65 years (Wareham et al 2002) It was decided that this short questionnaire shouldform the basis of the new measureA pilot study was conducted in three general practices with practice nursesadministering the self-completion of GPPAQ to 61 patients from a variety of newlyregistered patients including a number of patients for whom English was not the firstlanguage The GPPAQ was well received by nurses patients and generalpractitioners Practitioners welcomed a simple and efficient way of assessingphysical activity In particular they were keen to have a standardised way ofassigning Read Codes for physical activity The patients did not experience anyproblems in completing the questionnaire even when English was not the firstlanguageThe pilot study was limited to new registration appointments but most practitionerssuggested other possible uses for the GPPAQ including hypertension and diabetesclinics1 8Due to the positive findings of the pilot study a further study was conducted toexamine how reliable and accurate the GPPAQ was in routine general practice Foursurgeries were recruited in Coventry West Midlands Table 2 summarises thesurgeriesTable 2 Summary of study surgeriesPractice 1RegisteredpatientsNumberof GPsPatientCharacteristics1 10600 6

Mixed income70 white2 - -Low incomeMainly white3 11500 6Middle incomeMainly white4 - -Low income50 white5 14400 9Mixed income70 white6 6450 3Mixed incomeMainly whiteNB Practices 1 and 2 have two locations as do Practices 3 and 4

A Research Fellow (RF) of the University of Warwick recruited patients in the waitingrooms of the four surgeries The timing of recruiting visits to the surgeries wasvaried The routine nature of the recruitment meant that study participants werethose who normally attend general practice A total of 334 participants successfullycompleted the GPPAQ and a total of 258 participants completed it again a weeklater The PAI category allocated to each individual resulting from the completion ofthe second GPPAQ was compared with allocation to a physical activity categoryresulting from analysis of activity recorded for the same individual during thepreceding week using an Actigraph motion sensor Demographic characteristics ofparticipants who completed the first GPPAQ are summarised in Table 2Table 3 Participant characteristicsN GenderMaleFemale109223328672Age group18-2425-3435-4445-5455-6465-74226167746543

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

Participation in physical activity declines significantly with age for both sexes whilethe prevalence of those achieving less than 30 minutes of at least moderate intensityactivity increases with age and is markedly higher in some groups Only 17 of menand 13 of women between the ages of 65 and 74 meet the Chief Medical Officerrsquosrecommendation for physical activity This drops to 8 and 3 of men and womenrespectively over the age of 75Levels of physical activity also show an association with ethnicity With the exceptionof Black Caribbean and Irish populations all other minority ethnic groups have lowerrates of adherence to the Chief Medical Officerrsquos recommendations on physicalactivity for adults Inequalities are greatest for South Asian women Only 11 ofBangladeshi and 14 of Pakistani women were reported to have done therecommended amounts of physical activity compared with 25 in the generalpopulationThe Public Health White Paper Choosing health Making healthier choices easierreiterated the commitment to develop a patient activity questionnaire to support NHSstaff and others to understand their patientsrsquo levels of physical activity63 THE GPPAQ SCREENING TOOLA BACKGROUNDIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivity which could be used in routine general practice to assist Primary CareTrusts to meet the National Service Framework recommendations that primary careteams assess and record the modifiable risk factors for each of their patientsincluding physical activityThis questionnaire is called the GP Physical Activity Questionnaire and wasvalidated for patients aged 16-74 as a screening tool for physical activity levels inprimary careB INTENDED PURPOSEThe General Practice Physical Activity Questionnaire (GPPAQ) is a validatedscreening tool that1048707 Is used to assess adult (16 ndash 74 years) physical activity levels1048707 Provides a simple 4-level Physical Activity Index (PAI) of Active ModeratelyActive Moderately Inactive and Inactive That is correlated to CVD risk1048707 Is used to help inform a practitioner of when a brief intervention to increasephysical activity is appropriate All patients who receive a score less than Activeshould be offered a Brief Intervention in Physical Activity (NICE Guidance 2006)1048707 Is a useful screening tool for the Vascular Risk Health Checks programmeAlthough the questionnaire includes walking DIY green exercise and houseworkthese are not reflected in the final score due to significant over reporting observedduring validation and further questioning of walking amount and walking intensity isrequired in order to confirm the need for a brief intervention Details of how to probethe walking question are set out in annex 2The GPPAQ is appropriate for use in the NHS Health Check programme which willassess peoplersquos risk of heart disease stroke kidney disease and diabetes andsupport people to reduce or manage that risk through individually tailored advice Ifthrough GPPAQ the individual is identified as less than active practitioners shouldoffer a brief intervention in physical activityC TOOLS FOR PRACTICAL USE IN PRIMARY CAREThe General Practice Physical Activity Questionnaire comprises

bull A written questionnaire for completion by patients if completed outside of theconsultationbull Electronic template of the questionnaire (Excel) which can be completed duringthe consultation and automatically generates the Physical Activity Index (PAI)bull Coding algorithm (See Appendix 1)bull Read Codes for the PAI which can be used in patient record templatesThe DH is planning to incorporate the GPPAQ algorithm within patient recordsoftware it is currently only available through bolt on package frontdesk Until then7the electronic template of the questionnaire can be saved as a separate file for eachpatientPlease note that the coding algorithm is an integral part of the questionnaireAny unauthorised modification to the coding algorithm is likely to negate thevalidation of the questionnaireThere are specific read codes for the Physical Activity Index which can be integratedinto locally created templates within patient recordsThe GPPAQ algorithm classifies patients into one of four categories physicalactivity indexes ndash active moderately active moderately inactive inactiveMore detail is available in Annex 184 INSTRUCTIONS FOR USE IN PRIMARY CAREA HOW OFTEN TO USEThe level of physical activity should be entered on the clinical record for all patientsover the age of sixteen and should be updated at least every five years1For patients with clinical evidence of occlusive arterial disease and those whose riskof CHD events is greater than 30 over ten years physical activity levels should berecorded annuallyB EXCLUSIONS FOR USEThe GPPAQ was not evaluated for use in children and young people (aged lt16years) or adults older than 74 years Both groups may require age-specific physicalactivity assessmentsThe GPPAQ has not been designed for use as a research tool to measure selfreportedphysical activity before and after interventions and therefore is notappropriate for measuring the effectiveness of physical activity interventionsC COMPLETING THE QUESTIONNAIREThe General Practice Physical Activity Questionnaire takes approximately 30seconds to fill inGPPAQ can be completed1048707 By patients waiting for appointments1048707 In disease specific clinics1048707 In routine consultations1048707 In activity clinicsIt then takes a maximum of 1-2 minutes to transfer the responses to the electronictemplate and analyse the result The template will automatically assign a PhysicalActivity IndexD ANALYSING THE PHYSICAL ACTIVITY INDEX (PAI)Questions concerning walking houseworkchildcare and gardeningDIY are includedHowever they have not been shown to yield data of a sufficient reliability tocontribute to an objective assessment of overall physical activity levels and are notincluded in the calculation of the PAI

Where patients have reported that they walk regularly and their PAI is less thanactive a discussion is needed around the amount of and intensity of walking Thiswill help to determine whether the patient is currently meeting the Chief MedicalOfficerrsquos recommendation for 30 minutes of moderate activity on 5 days of the week(or more)1 Department of Health (2000) National Service Framework for CoronaryHeart Disease London Department of Health Chapter 2 Appendix A9Walking Gardening (Green exercise) Housework DIY activities can contribute tomeeting the Chief Medical Officerrsquos recommendation and walking in particularshould be encouragedAll patients who receive a score of less than active should be offered a BriefIntervention in Physical Activity in line with the NICE Guidance (2006)1 05 NICE PUBLIC HEALTH GUIDANCE FOUR COMMONLY USED METHODS TOINCREASE PHYSICAL ACTIVITY BRIEF INTERVENTIONSA BRIEF INTERVENTION IN PHYSICAL ACTIVITYNICE Public Health Intervention Guidance published in March 2006 endorsed BriefInterventions in Physical ActivityThe recommendations stipulated that primary care practitioners should1048707 Take the opportunity whenever possible to identify inactive adults1048707 Advise them to aim for 30 minutes of moderate activity on 5 days of the week(or more)1048707 Use their judgement to determine when this would be inappropriate (forexample because of medical conditions or personal circumstances)1048707 Use a validated tool such as the Department of Healthrsquos general practitionerphysical activity questionnaire (GPPAQ) to identify inactive individualsThe group with most to gain from an increase in physical activity are those with a PAIof 1 ie the lsquoInactiversquo It is estimated that 9 of CHD could be avoided if all thosewho are sedentary and moderately inactive became more moderately activehttpwwwniceorgukGuidancePH2GuidancepdfEnglishKey pointsIf through the validated tool GPPAQ the individual is identified as less than activepractitioners should offer a brief intervention in physical activity1048707 When providing physical activity advice primary care practitioners should takeinto account the individualrsquos needs preferences and circumstances1048707 They should agree goals with them They should also provide writteninformation about the benefits of activity and the local opportunities to beactive1048707 Where appropriate offer a referral into a condition specific or exercise onreferral programme if they are available locally1048707 They should follow them up at appropriate intervals over a 3 to 6 monthperiod1048707 Those with CHD risk of greater than 30 over ten years GPPAQ should becompleted annuallyThe lsquoActiversquo group should receive a degree of verbal reinforcement that reflects theircurrent level of physical activity and should be encouraged to either make smallincreases or continue with their current physical activity levelFor those who are classified as ldquoless than activerdquo through the GPPAQ but say thatthey walk further investigation is required into the frequency and intensity If the

practitioner deems the patient sufficiently active protocol for an ldquoactiverdquo patient canfollow For those who are still deemed inactive or unsure if they meet the CMOrecommendations or if a patient still expresses interest in increasing their physicalactivity levels a brief intervention can be given For details about how to discusswalking in greater detail please see Annex 21 1B PHYSICAL ACTIVITY CARE PATHWAYThe Department of Health has developed a Physical Activity Care Pathway to helpprimary care deliver the NICE Guidance for Brief InterventionsThis1048707 Uses the GPPAQ to screen patients for inactivity1048707 Follows the NICE guidance protocols detailed above to deliver a briefintervention including patient follow up at 36 and 12 months1048707 Uses the evidence based behaviour change technique MotivationalInterviewing to deliver the brief interventionThe Physical Activity Care Pathway has been positively evaluated by the BritishHeart Foundation National Centre for Physical Activity and Health at LoughboroughUniversity in a feasibility study in 14 surgeries that concluded in September 2008The Department of Health plans to launch the Physical Activity Care Pathwayresources in late 2009 This will include a commissioning toolkit and how to guide atraining package and patient resource pack1 2ANNEX 1A CALCULATING THE 4-LEVEL PHYSICAL ACTIVITY INDEX (PAI)Patients can be classified into four categories based on the original EPIC index fromwhich the GPPAQ was developedInactive Sedentary job and no physical exercise or cyclingModerately inactive Sedentary job and some but lt 1 hour physical exercise and orcycling per week ORStanding job and no physical exercise or cyclingModerately active Sedentary job and 1-29 hours physical exercise and or cyclingper week ORStanding job and some but lt 1 hour physical exercise and orcycling per week ORPhysical job and no physical exercise or cyclingActive Sedentary job and ge 3 hours physical exercise and or cyclingper week ORStanding job and 1-29 hours physical exercise and or cyclingper week ORPhysical job and some but lt 1 hour physical exercise and orcycling per week ORHeavy manual jobNote Questions concerning Walking HouseworkChildcare and GardeningDIY havebeen included to allow patients to record their physical activity in these categorieshowever these questions have not been shown to yield data of a sufficient reliabilityto contribute to an understanding of overall physical activity levels As noted abovefurther questioning is requiredB SUMMARY OF THE PAIOccupationPhysical exercise and or

cycling (hrwk)Sedentary Standing Physical Heavy Manual0 Inactive ModeratelyInactiveModeratelyActiveActiveSome but lt 1 ModeratelyInactiveModeratelyActiveActive Active1-29 ModeratelyActiveActive Active Activege 3 Active Active Active Active1 3C COMBINING RESPONSES FOR PHYSICAL EXERCISE AND CYCLINGCyclingPhysicalExercise0 Some but lt 1 1-29 ge30 0 Some but lt 1 1-29 ge3Some but lt 1 Some but lt 1 1-29 ge3 ge31-29 1-29 ge3 ge3 ge3ge3 ge3 ge3 ge3 ge3D GPPAQ READ CODES4 Byte Version 2 CTV3138X | GPPAQphyscl act indinactive138X | Generalpractice physicalactivity questionnairephysical activityindex inactiveXaPP8 | General practicephysical activityquestionnaire physicalactivity index inactive366121000000108 | General practicephysical activity questionnaire physicalactivity index inactive (finding)138Y | GPPAQphys act ind modinactv138Y | Generalpractice physicalactivity questionnairephysical activityindex moderatelyinactiveXaPPB | General practicephysical activityquestionnaire physicalactivity index moderately

inactive366171000000107 | General practicephysical activity questionnaire physicalactivity index moderately inactive(finding)138a | GPPAQphys act ind modactive138a | Generalpractice physicalactivity questionnairephysical activityindex moderatelyactiveXaPPD | General practicephysical activityquestionnaire physicalactivity index moderatelyactive366211000000105 | General practicephysical activity questionnaire physicalactivity index moderately active(finding)138b | GPPAQphysical act indactive138b | Generalpractice physicalactivity questionnairephysical activityindex activeXaPPE | General practicephysical activityquestionnaire physicalactivity index active366241000000106 | General practicephysical activity questionnaire physicalactivity index active (finding)1 4ANNEX 2A AN EXAMPLE OF A MOTIVATIONAL INTERVIEW WITHIN APHYSICAL ACTIVITY BRIEF INTERVENTIONPractitioners can consider the following example of a brief verbal intervention forInactive patients based on the principles of Motivational Interviewing (MI)Any intervention should be consistent with the agenda on patient led consultations andchoice One way to do this is to base behaviour-change negotiations on the principles ofmotivational interviewing (MI) Although developed in the field of addictions brief versions ofMI have been adapted and applied to a wide variety of behaviours and conditions such assmoking diet physical activity medical adherence and diabetes with evidence ofeffectiveness (Resnicow et al 2002 Rollnick 1999 Rubak 2005)Motivational Interviewing elicits change talk in the patient empowering them tochange their own behaviour Below are example questions for an MI based dialogueExample Dialogue for Inactive PatientsQuestion set OneldquoOn a scale from 0 to 10 where 0 is not important at all and 10 is extremely

important how important is getting more active for yourdquoldquoWhy did you pick this numberldquoldquoWhy did you not pick a lower numberldquoldquoWhat would you need to do to get you to a higher numberrdquoQuestion set TwoldquoNow think about why you want to do this Think about how yoursquoll feel whatyoursquoll look like what yoursquoll be able to do that you canrsquot do now Also thinkabout what might be stopping you from changing and what will happen if youdonrsquotrdquoWhy you want to changeeg To be able to play with children grandchildren To help healthWhat will happen if you changeeg more energy less lonely control conditionWhy you donrsquot want to changeeg low confidence donrsquot think will enjoy itWhat will happen if you donrsquoteg condition will get worse feel bad about self not be able to play withchildrengrandchildrenQuestion set ThreelsquoIf you were to decide to increase your physical activity how confident areyou that you would succeed If on a scale of 0 to 10 0 means that you are1 5not at all confident and 10 means that you are 100 confident you couldbecome more active What number would you give yourselfrdquoWhy did you pick this number on the scaleWhy did you not pick a lower numberWhat would you need to do to get a higher numberAll the while yoursquore trying elicit change talk from them and reaffirm these statementsback to the patientFinally provide the patient with a brief summary of what you heard and then askldquoWhat do you think the next step is for yourdquoYou can talk about the patients day and work with the patient about when activitycould be built in eg getting off the bus a stop early or walking children to schoolAnd also talk about activities that might be of interest to the patient whether itrsquosgardening dance swimming cycling walking or footballA common response is for the patient to say they donrsquot know or are uncertain If theydo follow withldquoLetrsquos list what the options are at the moment You couldStay as you are and do nothingStart to increase the amount of physical activity that you dordquoAgain this should illicit change talkGo through the patients day with them and talk about when activity could bebuilt in eg getting off the bus a stop early joining in a health walk or walkingthe children to schoolAlso talk about what activities might be of interest to them signpost to localactivities from gardening to dance to footballAsk the patient what they make of these opportunitiesIf interested talk to the patient about appropriate levels of activity and how tobuild up their activity levels If someone hasnrsquot been active for a long timegoing straight into vigorous activity isnrsquot a good idea advise patients to build

up their activity levels and intensity graduallyEncourage a patient to set a specific goal such asldquoI will go for a walk on Tuesday at lunchtime at the park for thirty minutes If Icanrsquot make it then I will go on WednesdayrdquoIn just a few minutes it is possible to encourage the patient to consider why and howthey might change their physical activity without feeling as if they are being pushedor coerced into something they are not ready for(Dialogue based on Rollnick et al 1997 Miller 2005 Rollnick et al 2005)1 6B ASSESSING INACTIVE PATIENTS WHO SELF REPORT 3 HOURSOR MORE PER WEEK OF WALKINGPatients who fall within the inactive category but claim to undertake significantamounts of walking may require a modified brief intervention that probes theirunderstanding of walking and walking pace and the basis upon which they havedeclared the amount of walking accumulated during the last week For those patientswho remain confident that they achieve the recommended levels of physical activityby virtue of their walking intensity and duration encourage them to continue Theexample dialogue given for Inactive patients could be prefaced with the followingldquoYou say you do three hours or more of walking per week So that I mightbetter understand how walking fits into your day perhaps you could talk methrough a typical day for you starting from when you get up in the morningright through to when you go to bed telling me where walking fits in Howabout yesterday could you talk me through yesterdayrdquoIf the patient insists the previous day was atypical use the day before that Try toavoid going too far back as the accuracy of recall will be diminished Thepractitionerrsquos task in this exercise is simply to listen without offering any judgementof what is being said This is not further assessment of the patientrsquos activity The aimis to get the patient talking about their current behaviour in a non-threatening (thethreat of being told to change) environment that will build rapport and conveys to thepatient that the practitioner listens and is genuinely interested in their situationEnsure you assess the level of intensity of walking you can use the following tool toassess intensity0 breathing easily conversation is easy1 breathing lightly and talking easily but heart rate increases2 still talking comfortably but breathing more quickly body warming up3 breathing more deeply and harder talking with a little more difficulty4 breathing very hard and short of breath cannot carry on a conversationLight Activity 0-1 Moderate Activity 2-3 Vigorous Activity 4Patients should be hitting 2-3 for the walking to count towards their activity levelOnce the patient has completed the description of their day the practitioner shouldsimply summarise the information on walking and then proceed to the motivation andconfidence questions described above as appropriate1 7ANNEX 3 GPPAQ TECHNICAL BACKGROUND AND EVALUATIONIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivityThe measure was intended for use in routine general practice and its purpose was toprovide a simple 4-level Physical Activity Index (PAI) reflecting an individualrsquos currentphysical activity The index would be used to decide when interventions to increase

physical activity might be appropriate A working title for the measure was theGeneral Practice Physical Activity Questionnaire (GPPAQ)After reviewing the literature and consultation with experts performancerequirements for the GPPAQ were agreed These were thatbull The method of completion should be self explanatorybull It should be designed for use by adults aged 18-74 years (later revised to 16-74 years)bull It should be possible for respondents to complete the questionnaire withoutassistancebull It should take less than one minute to completebull Individual physical activity categories should be simple requiring limitedcomputationbull The physical activity categories should allow for the assignment of a physicalactivity Read Codebull The output of the questionnaire should enable practice staff to make adecision on whether the patient concerned should be advised to be moreactive or whether more detailed assessment was requiredAlthough no existing self-report measure of physical activity had specifically beendeveloped for routine general practice a short physical activity questionnaire used inthe European Prospective Investigation into Cancer (EPIC) met many of the criteriaand a simple index of physical activity could be derived It had establishedacceptable levels of repeatability and validity in a sample of English adults aged 40-65 years (Wareham et al 2002) It was decided that this short questionnaire shouldform the basis of the new measureA pilot study was conducted in three general practices with practice nursesadministering the self-completion of GPPAQ to 61 patients from a variety of newlyregistered patients including a number of patients for whom English was not the firstlanguage The GPPAQ was well received by nurses patients and generalpractitioners Practitioners welcomed a simple and efficient way of assessingphysical activity In particular they were keen to have a standardised way ofassigning Read Codes for physical activity The patients did not experience anyproblems in completing the questionnaire even when English was not the firstlanguageThe pilot study was limited to new registration appointments but most practitionerssuggested other possible uses for the GPPAQ including hypertension and diabetesclinics1 8Due to the positive findings of the pilot study a further study was conducted toexamine how reliable and accurate the GPPAQ was in routine general practice Foursurgeries were recruited in Coventry West Midlands Table 2 summarises thesurgeriesTable 2 Summary of study surgeriesPractice 1RegisteredpatientsNumberof GPsPatientCharacteristics1 10600 6

Mixed income70 white2 - -Low incomeMainly white3 11500 6Middle incomeMainly white4 - -Low income50 white5 14400 9Mixed income70 white6 6450 3Mixed incomeMainly whiteNB Practices 1 and 2 have two locations as do Practices 3 and 4

A Research Fellow (RF) of the University of Warwick recruited patients in the waitingrooms of the four surgeries The timing of recruiting visits to the surgeries wasvaried The routine nature of the recruitment meant that study participants werethose who normally attend general practice A total of 334 participants successfullycompleted the GPPAQ and a total of 258 participants completed it again a weeklater The PAI category allocated to each individual resulting from the completion ofthe second GPPAQ was compared with allocation to a physical activity categoryresulting from analysis of activity recorded for the same individual during thepreceding week using an Actigraph motion sensor Demographic characteristics ofparticipants who completed the first GPPAQ are summarised in Table 2Table 3 Participant characteristicsN GenderMaleFemale109223328672Age group18-2425-3435-4445-5455-6465-74226167746543

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

bull A written questionnaire for completion by patients if completed outside of theconsultationbull Electronic template of the questionnaire (Excel) which can be completed duringthe consultation and automatically generates the Physical Activity Index (PAI)bull Coding algorithm (See Appendix 1)bull Read Codes for the PAI which can be used in patient record templatesThe DH is planning to incorporate the GPPAQ algorithm within patient recordsoftware it is currently only available through bolt on package frontdesk Until then7the electronic template of the questionnaire can be saved as a separate file for eachpatientPlease note that the coding algorithm is an integral part of the questionnaireAny unauthorised modification to the coding algorithm is likely to negate thevalidation of the questionnaireThere are specific read codes for the Physical Activity Index which can be integratedinto locally created templates within patient recordsThe GPPAQ algorithm classifies patients into one of four categories physicalactivity indexes ndash active moderately active moderately inactive inactiveMore detail is available in Annex 184 INSTRUCTIONS FOR USE IN PRIMARY CAREA HOW OFTEN TO USEThe level of physical activity should be entered on the clinical record for all patientsover the age of sixteen and should be updated at least every five years1For patients with clinical evidence of occlusive arterial disease and those whose riskof CHD events is greater than 30 over ten years physical activity levels should berecorded annuallyB EXCLUSIONS FOR USEThe GPPAQ was not evaluated for use in children and young people (aged lt16years) or adults older than 74 years Both groups may require age-specific physicalactivity assessmentsThe GPPAQ has not been designed for use as a research tool to measure selfreportedphysical activity before and after interventions and therefore is notappropriate for measuring the effectiveness of physical activity interventionsC COMPLETING THE QUESTIONNAIREThe General Practice Physical Activity Questionnaire takes approximately 30seconds to fill inGPPAQ can be completed1048707 By patients waiting for appointments1048707 In disease specific clinics1048707 In routine consultations1048707 In activity clinicsIt then takes a maximum of 1-2 minutes to transfer the responses to the electronictemplate and analyse the result The template will automatically assign a PhysicalActivity IndexD ANALYSING THE PHYSICAL ACTIVITY INDEX (PAI)Questions concerning walking houseworkchildcare and gardeningDIY are includedHowever they have not been shown to yield data of a sufficient reliability tocontribute to an objective assessment of overall physical activity levels and are notincluded in the calculation of the PAI

Where patients have reported that they walk regularly and their PAI is less thanactive a discussion is needed around the amount of and intensity of walking Thiswill help to determine whether the patient is currently meeting the Chief MedicalOfficerrsquos recommendation for 30 minutes of moderate activity on 5 days of the week(or more)1 Department of Health (2000) National Service Framework for CoronaryHeart Disease London Department of Health Chapter 2 Appendix A9Walking Gardening (Green exercise) Housework DIY activities can contribute tomeeting the Chief Medical Officerrsquos recommendation and walking in particularshould be encouragedAll patients who receive a score of less than active should be offered a BriefIntervention in Physical Activity in line with the NICE Guidance (2006)1 05 NICE PUBLIC HEALTH GUIDANCE FOUR COMMONLY USED METHODS TOINCREASE PHYSICAL ACTIVITY BRIEF INTERVENTIONSA BRIEF INTERVENTION IN PHYSICAL ACTIVITYNICE Public Health Intervention Guidance published in March 2006 endorsed BriefInterventions in Physical ActivityThe recommendations stipulated that primary care practitioners should1048707 Take the opportunity whenever possible to identify inactive adults1048707 Advise them to aim for 30 minutes of moderate activity on 5 days of the week(or more)1048707 Use their judgement to determine when this would be inappropriate (forexample because of medical conditions or personal circumstances)1048707 Use a validated tool such as the Department of Healthrsquos general practitionerphysical activity questionnaire (GPPAQ) to identify inactive individualsThe group with most to gain from an increase in physical activity are those with a PAIof 1 ie the lsquoInactiversquo It is estimated that 9 of CHD could be avoided if all thosewho are sedentary and moderately inactive became more moderately activehttpwwwniceorgukGuidancePH2GuidancepdfEnglishKey pointsIf through the validated tool GPPAQ the individual is identified as less than activepractitioners should offer a brief intervention in physical activity1048707 When providing physical activity advice primary care practitioners should takeinto account the individualrsquos needs preferences and circumstances1048707 They should agree goals with them They should also provide writteninformation about the benefits of activity and the local opportunities to beactive1048707 Where appropriate offer a referral into a condition specific or exercise onreferral programme if they are available locally1048707 They should follow them up at appropriate intervals over a 3 to 6 monthperiod1048707 Those with CHD risk of greater than 30 over ten years GPPAQ should becompleted annuallyThe lsquoActiversquo group should receive a degree of verbal reinforcement that reflects theircurrent level of physical activity and should be encouraged to either make smallincreases or continue with their current physical activity levelFor those who are classified as ldquoless than activerdquo through the GPPAQ but say thatthey walk further investigation is required into the frequency and intensity If the

practitioner deems the patient sufficiently active protocol for an ldquoactiverdquo patient canfollow For those who are still deemed inactive or unsure if they meet the CMOrecommendations or if a patient still expresses interest in increasing their physicalactivity levels a brief intervention can be given For details about how to discusswalking in greater detail please see Annex 21 1B PHYSICAL ACTIVITY CARE PATHWAYThe Department of Health has developed a Physical Activity Care Pathway to helpprimary care deliver the NICE Guidance for Brief InterventionsThis1048707 Uses the GPPAQ to screen patients for inactivity1048707 Follows the NICE guidance protocols detailed above to deliver a briefintervention including patient follow up at 36 and 12 months1048707 Uses the evidence based behaviour change technique MotivationalInterviewing to deliver the brief interventionThe Physical Activity Care Pathway has been positively evaluated by the BritishHeart Foundation National Centre for Physical Activity and Health at LoughboroughUniversity in a feasibility study in 14 surgeries that concluded in September 2008The Department of Health plans to launch the Physical Activity Care Pathwayresources in late 2009 This will include a commissioning toolkit and how to guide atraining package and patient resource pack1 2ANNEX 1A CALCULATING THE 4-LEVEL PHYSICAL ACTIVITY INDEX (PAI)Patients can be classified into four categories based on the original EPIC index fromwhich the GPPAQ was developedInactive Sedentary job and no physical exercise or cyclingModerately inactive Sedentary job and some but lt 1 hour physical exercise and orcycling per week ORStanding job and no physical exercise or cyclingModerately active Sedentary job and 1-29 hours physical exercise and or cyclingper week ORStanding job and some but lt 1 hour physical exercise and orcycling per week ORPhysical job and no physical exercise or cyclingActive Sedentary job and ge 3 hours physical exercise and or cyclingper week ORStanding job and 1-29 hours physical exercise and or cyclingper week ORPhysical job and some but lt 1 hour physical exercise and orcycling per week ORHeavy manual jobNote Questions concerning Walking HouseworkChildcare and GardeningDIY havebeen included to allow patients to record their physical activity in these categorieshowever these questions have not been shown to yield data of a sufficient reliabilityto contribute to an understanding of overall physical activity levels As noted abovefurther questioning is requiredB SUMMARY OF THE PAIOccupationPhysical exercise and or

cycling (hrwk)Sedentary Standing Physical Heavy Manual0 Inactive ModeratelyInactiveModeratelyActiveActiveSome but lt 1 ModeratelyInactiveModeratelyActiveActive Active1-29 ModeratelyActiveActive Active Activege 3 Active Active Active Active1 3C COMBINING RESPONSES FOR PHYSICAL EXERCISE AND CYCLINGCyclingPhysicalExercise0 Some but lt 1 1-29 ge30 0 Some but lt 1 1-29 ge3Some but lt 1 Some but lt 1 1-29 ge3 ge31-29 1-29 ge3 ge3 ge3ge3 ge3 ge3 ge3 ge3D GPPAQ READ CODES4 Byte Version 2 CTV3138X | GPPAQphyscl act indinactive138X | Generalpractice physicalactivity questionnairephysical activityindex inactiveXaPP8 | General practicephysical activityquestionnaire physicalactivity index inactive366121000000108 | General practicephysical activity questionnaire physicalactivity index inactive (finding)138Y | GPPAQphys act ind modinactv138Y | Generalpractice physicalactivity questionnairephysical activityindex moderatelyinactiveXaPPB | General practicephysical activityquestionnaire physicalactivity index moderately

inactive366171000000107 | General practicephysical activity questionnaire physicalactivity index moderately inactive(finding)138a | GPPAQphys act ind modactive138a | Generalpractice physicalactivity questionnairephysical activityindex moderatelyactiveXaPPD | General practicephysical activityquestionnaire physicalactivity index moderatelyactive366211000000105 | General practicephysical activity questionnaire physicalactivity index moderately active(finding)138b | GPPAQphysical act indactive138b | Generalpractice physicalactivity questionnairephysical activityindex activeXaPPE | General practicephysical activityquestionnaire physicalactivity index active366241000000106 | General practicephysical activity questionnaire physicalactivity index active (finding)1 4ANNEX 2A AN EXAMPLE OF A MOTIVATIONAL INTERVIEW WITHIN APHYSICAL ACTIVITY BRIEF INTERVENTIONPractitioners can consider the following example of a brief verbal intervention forInactive patients based on the principles of Motivational Interviewing (MI)Any intervention should be consistent with the agenda on patient led consultations andchoice One way to do this is to base behaviour-change negotiations on the principles ofmotivational interviewing (MI) Although developed in the field of addictions brief versions ofMI have been adapted and applied to a wide variety of behaviours and conditions such assmoking diet physical activity medical adherence and diabetes with evidence ofeffectiveness (Resnicow et al 2002 Rollnick 1999 Rubak 2005)Motivational Interviewing elicits change talk in the patient empowering them tochange their own behaviour Below are example questions for an MI based dialogueExample Dialogue for Inactive PatientsQuestion set OneldquoOn a scale from 0 to 10 where 0 is not important at all and 10 is extremely

important how important is getting more active for yourdquoldquoWhy did you pick this numberldquoldquoWhy did you not pick a lower numberldquoldquoWhat would you need to do to get you to a higher numberrdquoQuestion set TwoldquoNow think about why you want to do this Think about how yoursquoll feel whatyoursquoll look like what yoursquoll be able to do that you canrsquot do now Also thinkabout what might be stopping you from changing and what will happen if youdonrsquotrdquoWhy you want to changeeg To be able to play with children grandchildren To help healthWhat will happen if you changeeg more energy less lonely control conditionWhy you donrsquot want to changeeg low confidence donrsquot think will enjoy itWhat will happen if you donrsquoteg condition will get worse feel bad about self not be able to play withchildrengrandchildrenQuestion set ThreelsquoIf you were to decide to increase your physical activity how confident areyou that you would succeed If on a scale of 0 to 10 0 means that you are1 5not at all confident and 10 means that you are 100 confident you couldbecome more active What number would you give yourselfrdquoWhy did you pick this number on the scaleWhy did you not pick a lower numberWhat would you need to do to get a higher numberAll the while yoursquore trying elicit change talk from them and reaffirm these statementsback to the patientFinally provide the patient with a brief summary of what you heard and then askldquoWhat do you think the next step is for yourdquoYou can talk about the patients day and work with the patient about when activitycould be built in eg getting off the bus a stop early or walking children to schoolAnd also talk about activities that might be of interest to the patient whether itrsquosgardening dance swimming cycling walking or footballA common response is for the patient to say they donrsquot know or are uncertain If theydo follow withldquoLetrsquos list what the options are at the moment You couldStay as you are and do nothingStart to increase the amount of physical activity that you dordquoAgain this should illicit change talkGo through the patients day with them and talk about when activity could bebuilt in eg getting off the bus a stop early joining in a health walk or walkingthe children to schoolAlso talk about what activities might be of interest to them signpost to localactivities from gardening to dance to footballAsk the patient what they make of these opportunitiesIf interested talk to the patient about appropriate levels of activity and how tobuild up their activity levels If someone hasnrsquot been active for a long timegoing straight into vigorous activity isnrsquot a good idea advise patients to build

up their activity levels and intensity graduallyEncourage a patient to set a specific goal such asldquoI will go for a walk on Tuesday at lunchtime at the park for thirty minutes If Icanrsquot make it then I will go on WednesdayrdquoIn just a few minutes it is possible to encourage the patient to consider why and howthey might change their physical activity without feeling as if they are being pushedor coerced into something they are not ready for(Dialogue based on Rollnick et al 1997 Miller 2005 Rollnick et al 2005)1 6B ASSESSING INACTIVE PATIENTS WHO SELF REPORT 3 HOURSOR MORE PER WEEK OF WALKINGPatients who fall within the inactive category but claim to undertake significantamounts of walking may require a modified brief intervention that probes theirunderstanding of walking and walking pace and the basis upon which they havedeclared the amount of walking accumulated during the last week For those patientswho remain confident that they achieve the recommended levels of physical activityby virtue of their walking intensity and duration encourage them to continue Theexample dialogue given for Inactive patients could be prefaced with the followingldquoYou say you do three hours or more of walking per week So that I mightbetter understand how walking fits into your day perhaps you could talk methrough a typical day for you starting from when you get up in the morningright through to when you go to bed telling me where walking fits in Howabout yesterday could you talk me through yesterdayrdquoIf the patient insists the previous day was atypical use the day before that Try toavoid going too far back as the accuracy of recall will be diminished Thepractitionerrsquos task in this exercise is simply to listen without offering any judgementof what is being said This is not further assessment of the patientrsquos activity The aimis to get the patient talking about their current behaviour in a non-threatening (thethreat of being told to change) environment that will build rapport and conveys to thepatient that the practitioner listens and is genuinely interested in their situationEnsure you assess the level of intensity of walking you can use the following tool toassess intensity0 breathing easily conversation is easy1 breathing lightly and talking easily but heart rate increases2 still talking comfortably but breathing more quickly body warming up3 breathing more deeply and harder talking with a little more difficulty4 breathing very hard and short of breath cannot carry on a conversationLight Activity 0-1 Moderate Activity 2-3 Vigorous Activity 4Patients should be hitting 2-3 for the walking to count towards their activity levelOnce the patient has completed the description of their day the practitioner shouldsimply summarise the information on walking and then proceed to the motivation andconfidence questions described above as appropriate1 7ANNEX 3 GPPAQ TECHNICAL BACKGROUND AND EVALUATIONIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivityThe measure was intended for use in routine general practice and its purpose was toprovide a simple 4-level Physical Activity Index (PAI) reflecting an individualrsquos currentphysical activity The index would be used to decide when interventions to increase

physical activity might be appropriate A working title for the measure was theGeneral Practice Physical Activity Questionnaire (GPPAQ)After reviewing the literature and consultation with experts performancerequirements for the GPPAQ were agreed These were thatbull The method of completion should be self explanatorybull It should be designed for use by adults aged 18-74 years (later revised to 16-74 years)bull It should be possible for respondents to complete the questionnaire withoutassistancebull It should take less than one minute to completebull Individual physical activity categories should be simple requiring limitedcomputationbull The physical activity categories should allow for the assignment of a physicalactivity Read Codebull The output of the questionnaire should enable practice staff to make adecision on whether the patient concerned should be advised to be moreactive or whether more detailed assessment was requiredAlthough no existing self-report measure of physical activity had specifically beendeveloped for routine general practice a short physical activity questionnaire used inthe European Prospective Investigation into Cancer (EPIC) met many of the criteriaand a simple index of physical activity could be derived It had establishedacceptable levels of repeatability and validity in a sample of English adults aged 40-65 years (Wareham et al 2002) It was decided that this short questionnaire shouldform the basis of the new measureA pilot study was conducted in three general practices with practice nursesadministering the self-completion of GPPAQ to 61 patients from a variety of newlyregistered patients including a number of patients for whom English was not the firstlanguage The GPPAQ was well received by nurses patients and generalpractitioners Practitioners welcomed a simple and efficient way of assessingphysical activity In particular they were keen to have a standardised way ofassigning Read Codes for physical activity The patients did not experience anyproblems in completing the questionnaire even when English was not the firstlanguageThe pilot study was limited to new registration appointments but most practitionerssuggested other possible uses for the GPPAQ including hypertension and diabetesclinics1 8Due to the positive findings of the pilot study a further study was conducted toexamine how reliable and accurate the GPPAQ was in routine general practice Foursurgeries were recruited in Coventry West Midlands Table 2 summarises thesurgeriesTable 2 Summary of study surgeriesPractice 1RegisteredpatientsNumberof GPsPatientCharacteristics1 10600 6

Mixed income70 white2 - -Low incomeMainly white3 11500 6Middle incomeMainly white4 - -Low income50 white5 14400 9Mixed income70 white6 6450 3Mixed incomeMainly whiteNB Practices 1 and 2 have two locations as do Practices 3 and 4

A Research Fellow (RF) of the University of Warwick recruited patients in the waitingrooms of the four surgeries The timing of recruiting visits to the surgeries wasvaried The routine nature of the recruitment meant that study participants werethose who normally attend general practice A total of 334 participants successfullycompleted the GPPAQ and a total of 258 participants completed it again a weeklater The PAI category allocated to each individual resulting from the completion ofthe second GPPAQ was compared with allocation to a physical activity categoryresulting from analysis of activity recorded for the same individual during thepreceding week using an Actigraph motion sensor Demographic characteristics ofparticipants who completed the first GPPAQ are summarised in Table 2Table 3 Participant characteristicsN GenderMaleFemale109223328672Age group18-2425-3435-4445-5455-6465-74226167746543

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

Where patients have reported that they walk regularly and their PAI is less thanactive a discussion is needed around the amount of and intensity of walking Thiswill help to determine whether the patient is currently meeting the Chief MedicalOfficerrsquos recommendation for 30 minutes of moderate activity on 5 days of the week(or more)1 Department of Health (2000) National Service Framework for CoronaryHeart Disease London Department of Health Chapter 2 Appendix A9Walking Gardening (Green exercise) Housework DIY activities can contribute tomeeting the Chief Medical Officerrsquos recommendation and walking in particularshould be encouragedAll patients who receive a score of less than active should be offered a BriefIntervention in Physical Activity in line with the NICE Guidance (2006)1 05 NICE PUBLIC HEALTH GUIDANCE FOUR COMMONLY USED METHODS TOINCREASE PHYSICAL ACTIVITY BRIEF INTERVENTIONSA BRIEF INTERVENTION IN PHYSICAL ACTIVITYNICE Public Health Intervention Guidance published in March 2006 endorsed BriefInterventions in Physical ActivityThe recommendations stipulated that primary care practitioners should1048707 Take the opportunity whenever possible to identify inactive adults1048707 Advise them to aim for 30 minutes of moderate activity on 5 days of the week(or more)1048707 Use their judgement to determine when this would be inappropriate (forexample because of medical conditions or personal circumstances)1048707 Use a validated tool such as the Department of Healthrsquos general practitionerphysical activity questionnaire (GPPAQ) to identify inactive individualsThe group with most to gain from an increase in physical activity are those with a PAIof 1 ie the lsquoInactiversquo It is estimated that 9 of CHD could be avoided if all thosewho are sedentary and moderately inactive became more moderately activehttpwwwniceorgukGuidancePH2GuidancepdfEnglishKey pointsIf through the validated tool GPPAQ the individual is identified as less than activepractitioners should offer a brief intervention in physical activity1048707 When providing physical activity advice primary care practitioners should takeinto account the individualrsquos needs preferences and circumstances1048707 They should agree goals with them They should also provide writteninformation about the benefits of activity and the local opportunities to beactive1048707 Where appropriate offer a referral into a condition specific or exercise onreferral programme if they are available locally1048707 They should follow them up at appropriate intervals over a 3 to 6 monthperiod1048707 Those with CHD risk of greater than 30 over ten years GPPAQ should becompleted annuallyThe lsquoActiversquo group should receive a degree of verbal reinforcement that reflects theircurrent level of physical activity and should be encouraged to either make smallincreases or continue with their current physical activity levelFor those who are classified as ldquoless than activerdquo through the GPPAQ but say thatthey walk further investigation is required into the frequency and intensity If the

practitioner deems the patient sufficiently active protocol for an ldquoactiverdquo patient canfollow For those who are still deemed inactive or unsure if they meet the CMOrecommendations or if a patient still expresses interest in increasing their physicalactivity levels a brief intervention can be given For details about how to discusswalking in greater detail please see Annex 21 1B PHYSICAL ACTIVITY CARE PATHWAYThe Department of Health has developed a Physical Activity Care Pathway to helpprimary care deliver the NICE Guidance for Brief InterventionsThis1048707 Uses the GPPAQ to screen patients for inactivity1048707 Follows the NICE guidance protocols detailed above to deliver a briefintervention including patient follow up at 36 and 12 months1048707 Uses the evidence based behaviour change technique MotivationalInterviewing to deliver the brief interventionThe Physical Activity Care Pathway has been positively evaluated by the BritishHeart Foundation National Centre for Physical Activity and Health at LoughboroughUniversity in a feasibility study in 14 surgeries that concluded in September 2008The Department of Health plans to launch the Physical Activity Care Pathwayresources in late 2009 This will include a commissioning toolkit and how to guide atraining package and patient resource pack1 2ANNEX 1A CALCULATING THE 4-LEVEL PHYSICAL ACTIVITY INDEX (PAI)Patients can be classified into four categories based on the original EPIC index fromwhich the GPPAQ was developedInactive Sedentary job and no physical exercise or cyclingModerately inactive Sedentary job and some but lt 1 hour physical exercise and orcycling per week ORStanding job and no physical exercise or cyclingModerately active Sedentary job and 1-29 hours physical exercise and or cyclingper week ORStanding job and some but lt 1 hour physical exercise and orcycling per week ORPhysical job and no physical exercise or cyclingActive Sedentary job and ge 3 hours physical exercise and or cyclingper week ORStanding job and 1-29 hours physical exercise and or cyclingper week ORPhysical job and some but lt 1 hour physical exercise and orcycling per week ORHeavy manual jobNote Questions concerning Walking HouseworkChildcare and GardeningDIY havebeen included to allow patients to record their physical activity in these categorieshowever these questions have not been shown to yield data of a sufficient reliabilityto contribute to an understanding of overall physical activity levels As noted abovefurther questioning is requiredB SUMMARY OF THE PAIOccupationPhysical exercise and or

cycling (hrwk)Sedentary Standing Physical Heavy Manual0 Inactive ModeratelyInactiveModeratelyActiveActiveSome but lt 1 ModeratelyInactiveModeratelyActiveActive Active1-29 ModeratelyActiveActive Active Activege 3 Active Active Active Active1 3C COMBINING RESPONSES FOR PHYSICAL EXERCISE AND CYCLINGCyclingPhysicalExercise0 Some but lt 1 1-29 ge30 0 Some but lt 1 1-29 ge3Some but lt 1 Some but lt 1 1-29 ge3 ge31-29 1-29 ge3 ge3 ge3ge3 ge3 ge3 ge3 ge3D GPPAQ READ CODES4 Byte Version 2 CTV3138X | GPPAQphyscl act indinactive138X | Generalpractice physicalactivity questionnairephysical activityindex inactiveXaPP8 | General practicephysical activityquestionnaire physicalactivity index inactive366121000000108 | General practicephysical activity questionnaire physicalactivity index inactive (finding)138Y | GPPAQphys act ind modinactv138Y | Generalpractice physicalactivity questionnairephysical activityindex moderatelyinactiveXaPPB | General practicephysical activityquestionnaire physicalactivity index moderately

inactive366171000000107 | General practicephysical activity questionnaire physicalactivity index moderately inactive(finding)138a | GPPAQphys act ind modactive138a | Generalpractice physicalactivity questionnairephysical activityindex moderatelyactiveXaPPD | General practicephysical activityquestionnaire physicalactivity index moderatelyactive366211000000105 | General practicephysical activity questionnaire physicalactivity index moderately active(finding)138b | GPPAQphysical act indactive138b | Generalpractice physicalactivity questionnairephysical activityindex activeXaPPE | General practicephysical activityquestionnaire physicalactivity index active366241000000106 | General practicephysical activity questionnaire physicalactivity index active (finding)1 4ANNEX 2A AN EXAMPLE OF A MOTIVATIONAL INTERVIEW WITHIN APHYSICAL ACTIVITY BRIEF INTERVENTIONPractitioners can consider the following example of a brief verbal intervention forInactive patients based on the principles of Motivational Interviewing (MI)Any intervention should be consistent with the agenda on patient led consultations andchoice One way to do this is to base behaviour-change negotiations on the principles ofmotivational interviewing (MI) Although developed in the field of addictions brief versions ofMI have been adapted and applied to a wide variety of behaviours and conditions such assmoking diet physical activity medical adherence and diabetes with evidence ofeffectiveness (Resnicow et al 2002 Rollnick 1999 Rubak 2005)Motivational Interviewing elicits change talk in the patient empowering them tochange their own behaviour Below are example questions for an MI based dialogueExample Dialogue for Inactive PatientsQuestion set OneldquoOn a scale from 0 to 10 where 0 is not important at all and 10 is extremely

important how important is getting more active for yourdquoldquoWhy did you pick this numberldquoldquoWhy did you not pick a lower numberldquoldquoWhat would you need to do to get you to a higher numberrdquoQuestion set TwoldquoNow think about why you want to do this Think about how yoursquoll feel whatyoursquoll look like what yoursquoll be able to do that you canrsquot do now Also thinkabout what might be stopping you from changing and what will happen if youdonrsquotrdquoWhy you want to changeeg To be able to play with children grandchildren To help healthWhat will happen if you changeeg more energy less lonely control conditionWhy you donrsquot want to changeeg low confidence donrsquot think will enjoy itWhat will happen if you donrsquoteg condition will get worse feel bad about self not be able to play withchildrengrandchildrenQuestion set ThreelsquoIf you were to decide to increase your physical activity how confident areyou that you would succeed If on a scale of 0 to 10 0 means that you are1 5not at all confident and 10 means that you are 100 confident you couldbecome more active What number would you give yourselfrdquoWhy did you pick this number on the scaleWhy did you not pick a lower numberWhat would you need to do to get a higher numberAll the while yoursquore trying elicit change talk from them and reaffirm these statementsback to the patientFinally provide the patient with a brief summary of what you heard and then askldquoWhat do you think the next step is for yourdquoYou can talk about the patients day and work with the patient about when activitycould be built in eg getting off the bus a stop early or walking children to schoolAnd also talk about activities that might be of interest to the patient whether itrsquosgardening dance swimming cycling walking or footballA common response is for the patient to say they donrsquot know or are uncertain If theydo follow withldquoLetrsquos list what the options are at the moment You couldStay as you are and do nothingStart to increase the amount of physical activity that you dordquoAgain this should illicit change talkGo through the patients day with them and talk about when activity could bebuilt in eg getting off the bus a stop early joining in a health walk or walkingthe children to schoolAlso talk about what activities might be of interest to them signpost to localactivities from gardening to dance to footballAsk the patient what they make of these opportunitiesIf interested talk to the patient about appropriate levels of activity and how tobuild up their activity levels If someone hasnrsquot been active for a long timegoing straight into vigorous activity isnrsquot a good idea advise patients to build

up their activity levels and intensity graduallyEncourage a patient to set a specific goal such asldquoI will go for a walk on Tuesday at lunchtime at the park for thirty minutes If Icanrsquot make it then I will go on WednesdayrdquoIn just a few minutes it is possible to encourage the patient to consider why and howthey might change their physical activity without feeling as if they are being pushedor coerced into something they are not ready for(Dialogue based on Rollnick et al 1997 Miller 2005 Rollnick et al 2005)1 6B ASSESSING INACTIVE PATIENTS WHO SELF REPORT 3 HOURSOR MORE PER WEEK OF WALKINGPatients who fall within the inactive category but claim to undertake significantamounts of walking may require a modified brief intervention that probes theirunderstanding of walking and walking pace and the basis upon which they havedeclared the amount of walking accumulated during the last week For those patientswho remain confident that they achieve the recommended levels of physical activityby virtue of their walking intensity and duration encourage them to continue Theexample dialogue given for Inactive patients could be prefaced with the followingldquoYou say you do three hours or more of walking per week So that I mightbetter understand how walking fits into your day perhaps you could talk methrough a typical day for you starting from when you get up in the morningright through to when you go to bed telling me where walking fits in Howabout yesterday could you talk me through yesterdayrdquoIf the patient insists the previous day was atypical use the day before that Try toavoid going too far back as the accuracy of recall will be diminished Thepractitionerrsquos task in this exercise is simply to listen without offering any judgementof what is being said This is not further assessment of the patientrsquos activity The aimis to get the patient talking about their current behaviour in a non-threatening (thethreat of being told to change) environment that will build rapport and conveys to thepatient that the practitioner listens and is genuinely interested in their situationEnsure you assess the level of intensity of walking you can use the following tool toassess intensity0 breathing easily conversation is easy1 breathing lightly and talking easily but heart rate increases2 still talking comfortably but breathing more quickly body warming up3 breathing more deeply and harder talking with a little more difficulty4 breathing very hard and short of breath cannot carry on a conversationLight Activity 0-1 Moderate Activity 2-3 Vigorous Activity 4Patients should be hitting 2-3 for the walking to count towards their activity levelOnce the patient has completed the description of their day the practitioner shouldsimply summarise the information on walking and then proceed to the motivation andconfidence questions described above as appropriate1 7ANNEX 3 GPPAQ TECHNICAL BACKGROUND AND EVALUATIONIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivityThe measure was intended for use in routine general practice and its purpose was toprovide a simple 4-level Physical Activity Index (PAI) reflecting an individualrsquos currentphysical activity The index would be used to decide when interventions to increase

physical activity might be appropriate A working title for the measure was theGeneral Practice Physical Activity Questionnaire (GPPAQ)After reviewing the literature and consultation with experts performancerequirements for the GPPAQ were agreed These were thatbull The method of completion should be self explanatorybull It should be designed for use by adults aged 18-74 years (later revised to 16-74 years)bull It should be possible for respondents to complete the questionnaire withoutassistancebull It should take less than one minute to completebull Individual physical activity categories should be simple requiring limitedcomputationbull The physical activity categories should allow for the assignment of a physicalactivity Read Codebull The output of the questionnaire should enable practice staff to make adecision on whether the patient concerned should be advised to be moreactive or whether more detailed assessment was requiredAlthough no existing self-report measure of physical activity had specifically beendeveloped for routine general practice a short physical activity questionnaire used inthe European Prospective Investigation into Cancer (EPIC) met many of the criteriaand a simple index of physical activity could be derived It had establishedacceptable levels of repeatability and validity in a sample of English adults aged 40-65 years (Wareham et al 2002) It was decided that this short questionnaire shouldform the basis of the new measureA pilot study was conducted in three general practices with practice nursesadministering the self-completion of GPPAQ to 61 patients from a variety of newlyregistered patients including a number of patients for whom English was not the firstlanguage The GPPAQ was well received by nurses patients and generalpractitioners Practitioners welcomed a simple and efficient way of assessingphysical activity In particular they were keen to have a standardised way ofassigning Read Codes for physical activity The patients did not experience anyproblems in completing the questionnaire even when English was not the firstlanguageThe pilot study was limited to new registration appointments but most practitionerssuggested other possible uses for the GPPAQ including hypertension and diabetesclinics1 8Due to the positive findings of the pilot study a further study was conducted toexamine how reliable and accurate the GPPAQ was in routine general practice Foursurgeries were recruited in Coventry West Midlands Table 2 summarises thesurgeriesTable 2 Summary of study surgeriesPractice 1RegisteredpatientsNumberof GPsPatientCharacteristics1 10600 6

Mixed income70 white2 - -Low incomeMainly white3 11500 6Middle incomeMainly white4 - -Low income50 white5 14400 9Mixed income70 white6 6450 3Mixed incomeMainly whiteNB Practices 1 and 2 have two locations as do Practices 3 and 4

A Research Fellow (RF) of the University of Warwick recruited patients in the waitingrooms of the four surgeries The timing of recruiting visits to the surgeries wasvaried The routine nature of the recruitment meant that study participants werethose who normally attend general practice A total of 334 participants successfullycompleted the GPPAQ and a total of 258 participants completed it again a weeklater The PAI category allocated to each individual resulting from the completion ofthe second GPPAQ was compared with allocation to a physical activity categoryresulting from analysis of activity recorded for the same individual during thepreceding week using an Actigraph motion sensor Demographic characteristics ofparticipants who completed the first GPPAQ are summarised in Table 2Table 3 Participant characteristicsN GenderMaleFemale109223328672Age group18-2425-3435-4445-5455-6465-74226167746543

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

practitioner deems the patient sufficiently active protocol for an ldquoactiverdquo patient canfollow For those who are still deemed inactive or unsure if they meet the CMOrecommendations or if a patient still expresses interest in increasing their physicalactivity levels a brief intervention can be given For details about how to discusswalking in greater detail please see Annex 21 1B PHYSICAL ACTIVITY CARE PATHWAYThe Department of Health has developed a Physical Activity Care Pathway to helpprimary care deliver the NICE Guidance for Brief InterventionsThis1048707 Uses the GPPAQ to screen patients for inactivity1048707 Follows the NICE guidance protocols detailed above to deliver a briefintervention including patient follow up at 36 and 12 months1048707 Uses the evidence based behaviour change technique MotivationalInterviewing to deliver the brief interventionThe Physical Activity Care Pathway has been positively evaluated by the BritishHeart Foundation National Centre for Physical Activity and Health at LoughboroughUniversity in a feasibility study in 14 surgeries that concluded in September 2008The Department of Health plans to launch the Physical Activity Care Pathwayresources in late 2009 This will include a commissioning toolkit and how to guide atraining package and patient resource pack1 2ANNEX 1A CALCULATING THE 4-LEVEL PHYSICAL ACTIVITY INDEX (PAI)Patients can be classified into four categories based on the original EPIC index fromwhich the GPPAQ was developedInactive Sedentary job and no physical exercise or cyclingModerately inactive Sedentary job and some but lt 1 hour physical exercise and orcycling per week ORStanding job and no physical exercise or cyclingModerately active Sedentary job and 1-29 hours physical exercise and or cyclingper week ORStanding job and some but lt 1 hour physical exercise and orcycling per week ORPhysical job and no physical exercise or cyclingActive Sedentary job and ge 3 hours physical exercise and or cyclingper week ORStanding job and 1-29 hours physical exercise and or cyclingper week ORPhysical job and some but lt 1 hour physical exercise and orcycling per week ORHeavy manual jobNote Questions concerning Walking HouseworkChildcare and GardeningDIY havebeen included to allow patients to record their physical activity in these categorieshowever these questions have not been shown to yield data of a sufficient reliabilityto contribute to an understanding of overall physical activity levels As noted abovefurther questioning is requiredB SUMMARY OF THE PAIOccupationPhysical exercise and or

cycling (hrwk)Sedentary Standing Physical Heavy Manual0 Inactive ModeratelyInactiveModeratelyActiveActiveSome but lt 1 ModeratelyInactiveModeratelyActiveActive Active1-29 ModeratelyActiveActive Active Activege 3 Active Active Active Active1 3C COMBINING RESPONSES FOR PHYSICAL EXERCISE AND CYCLINGCyclingPhysicalExercise0 Some but lt 1 1-29 ge30 0 Some but lt 1 1-29 ge3Some but lt 1 Some but lt 1 1-29 ge3 ge31-29 1-29 ge3 ge3 ge3ge3 ge3 ge3 ge3 ge3D GPPAQ READ CODES4 Byte Version 2 CTV3138X | GPPAQphyscl act indinactive138X | Generalpractice physicalactivity questionnairephysical activityindex inactiveXaPP8 | General practicephysical activityquestionnaire physicalactivity index inactive366121000000108 | General practicephysical activity questionnaire physicalactivity index inactive (finding)138Y | GPPAQphys act ind modinactv138Y | Generalpractice physicalactivity questionnairephysical activityindex moderatelyinactiveXaPPB | General practicephysical activityquestionnaire physicalactivity index moderately

inactive366171000000107 | General practicephysical activity questionnaire physicalactivity index moderately inactive(finding)138a | GPPAQphys act ind modactive138a | Generalpractice physicalactivity questionnairephysical activityindex moderatelyactiveXaPPD | General practicephysical activityquestionnaire physicalactivity index moderatelyactive366211000000105 | General practicephysical activity questionnaire physicalactivity index moderately active(finding)138b | GPPAQphysical act indactive138b | Generalpractice physicalactivity questionnairephysical activityindex activeXaPPE | General practicephysical activityquestionnaire physicalactivity index active366241000000106 | General practicephysical activity questionnaire physicalactivity index active (finding)1 4ANNEX 2A AN EXAMPLE OF A MOTIVATIONAL INTERVIEW WITHIN APHYSICAL ACTIVITY BRIEF INTERVENTIONPractitioners can consider the following example of a brief verbal intervention forInactive patients based on the principles of Motivational Interviewing (MI)Any intervention should be consistent with the agenda on patient led consultations andchoice One way to do this is to base behaviour-change negotiations on the principles ofmotivational interviewing (MI) Although developed in the field of addictions brief versions ofMI have been adapted and applied to a wide variety of behaviours and conditions such assmoking diet physical activity medical adherence and diabetes with evidence ofeffectiveness (Resnicow et al 2002 Rollnick 1999 Rubak 2005)Motivational Interviewing elicits change talk in the patient empowering them tochange their own behaviour Below are example questions for an MI based dialogueExample Dialogue for Inactive PatientsQuestion set OneldquoOn a scale from 0 to 10 where 0 is not important at all and 10 is extremely

important how important is getting more active for yourdquoldquoWhy did you pick this numberldquoldquoWhy did you not pick a lower numberldquoldquoWhat would you need to do to get you to a higher numberrdquoQuestion set TwoldquoNow think about why you want to do this Think about how yoursquoll feel whatyoursquoll look like what yoursquoll be able to do that you canrsquot do now Also thinkabout what might be stopping you from changing and what will happen if youdonrsquotrdquoWhy you want to changeeg To be able to play with children grandchildren To help healthWhat will happen if you changeeg more energy less lonely control conditionWhy you donrsquot want to changeeg low confidence donrsquot think will enjoy itWhat will happen if you donrsquoteg condition will get worse feel bad about self not be able to play withchildrengrandchildrenQuestion set ThreelsquoIf you were to decide to increase your physical activity how confident areyou that you would succeed If on a scale of 0 to 10 0 means that you are1 5not at all confident and 10 means that you are 100 confident you couldbecome more active What number would you give yourselfrdquoWhy did you pick this number on the scaleWhy did you not pick a lower numberWhat would you need to do to get a higher numberAll the while yoursquore trying elicit change talk from them and reaffirm these statementsback to the patientFinally provide the patient with a brief summary of what you heard and then askldquoWhat do you think the next step is for yourdquoYou can talk about the patients day and work with the patient about when activitycould be built in eg getting off the bus a stop early or walking children to schoolAnd also talk about activities that might be of interest to the patient whether itrsquosgardening dance swimming cycling walking or footballA common response is for the patient to say they donrsquot know or are uncertain If theydo follow withldquoLetrsquos list what the options are at the moment You couldStay as you are and do nothingStart to increase the amount of physical activity that you dordquoAgain this should illicit change talkGo through the patients day with them and talk about when activity could bebuilt in eg getting off the bus a stop early joining in a health walk or walkingthe children to schoolAlso talk about what activities might be of interest to them signpost to localactivities from gardening to dance to footballAsk the patient what they make of these opportunitiesIf interested talk to the patient about appropriate levels of activity and how tobuild up their activity levels If someone hasnrsquot been active for a long timegoing straight into vigorous activity isnrsquot a good idea advise patients to build

up their activity levels and intensity graduallyEncourage a patient to set a specific goal such asldquoI will go for a walk on Tuesday at lunchtime at the park for thirty minutes If Icanrsquot make it then I will go on WednesdayrdquoIn just a few minutes it is possible to encourage the patient to consider why and howthey might change their physical activity without feeling as if they are being pushedor coerced into something they are not ready for(Dialogue based on Rollnick et al 1997 Miller 2005 Rollnick et al 2005)1 6B ASSESSING INACTIVE PATIENTS WHO SELF REPORT 3 HOURSOR MORE PER WEEK OF WALKINGPatients who fall within the inactive category but claim to undertake significantamounts of walking may require a modified brief intervention that probes theirunderstanding of walking and walking pace and the basis upon which they havedeclared the amount of walking accumulated during the last week For those patientswho remain confident that they achieve the recommended levels of physical activityby virtue of their walking intensity and duration encourage them to continue Theexample dialogue given for Inactive patients could be prefaced with the followingldquoYou say you do three hours or more of walking per week So that I mightbetter understand how walking fits into your day perhaps you could talk methrough a typical day for you starting from when you get up in the morningright through to when you go to bed telling me where walking fits in Howabout yesterday could you talk me through yesterdayrdquoIf the patient insists the previous day was atypical use the day before that Try toavoid going too far back as the accuracy of recall will be diminished Thepractitionerrsquos task in this exercise is simply to listen without offering any judgementof what is being said This is not further assessment of the patientrsquos activity The aimis to get the patient talking about their current behaviour in a non-threatening (thethreat of being told to change) environment that will build rapport and conveys to thepatient that the practitioner listens and is genuinely interested in their situationEnsure you assess the level of intensity of walking you can use the following tool toassess intensity0 breathing easily conversation is easy1 breathing lightly and talking easily but heart rate increases2 still talking comfortably but breathing more quickly body warming up3 breathing more deeply and harder talking with a little more difficulty4 breathing very hard and short of breath cannot carry on a conversationLight Activity 0-1 Moderate Activity 2-3 Vigorous Activity 4Patients should be hitting 2-3 for the walking to count towards their activity levelOnce the patient has completed the description of their day the practitioner shouldsimply summarise the information on walking and then proceed to the motivation andconfidence questions described above as appropriate1 7ANNEX 3 GPPAQ TECHNICAL BACKGROUND AND EVALUATIONIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivityThe measure was intended for use in routine general practice and its purpose was toprovide a simple 4-level Physical Activity Index (PAI) reflecting an individualrsquos currentphysical activity The index would be used to decide when interventions to increase

physical activity might be appropriate A working title for the measure was theGeneral Practice Physical Activity Questionnaire (GPPAQ)After reviewing the literature and consultation with experts performancerequirements for the GPPAQ were agreed These were thatbull The method of completion should be self explanatorybull It should be designed for use by adults aged 18-74 years (later revised to 16-74 years)bull It should be possible for respondents to complete the questionnaire withoutassistancebull It should take less than one minute to completebull Individual physical activity categories should be simple requiring limitedcomputationbull The physical activity categories should allow for the assignment of a physicalactivity Read Codebull The output of the questionnaire should enable practice staff to make adecision on whether the patient concerned should be advised to be moreactive or whether more detailed assessment was requiredAlthough no existing self-report measure of physical activity had specifically beendeveloped for routine general practice a short physical activity questionnaire used inthe European Prospective Investigation into Cancer (EPIC) met many of the criteriaand a simple index of physical activity could be derived It had establishedacceptable levels of repeatability and validity in a sample of English adults aged 40-65 years (Wareham et al 2002) It was decided that this short questionnaire shouldform the basis of the new measureA pilot study was conducted in three general practices with practice nursesadministering the self-completion of GPPAQ to 61 patients from a variety of newlyregistered patients including a number of patients for whom English was not the firstlanguage The GPPAQ was well received by nurses patients and generalpractitioners Practitioners welcomed a simple and efficient way of assessingphysical activity In particular they were keen to have a standardised way ofassigning Read Codes for physical activity The patients did not experience anyproblems in completing the questionnaire even when English was not the firstlanguageThe pilot study was limited to new registration appointments but most practitionerssuggested other possible uses for the GPPAQ including hypertension and diabetesclinics1 8Due to the positive findings of the pilot study a further study was conducted toexamine how reliable and accurate the GPPAQ was in routine general practice Foursurgeries were recruited in Coventry West Midlands Table 2 summarises thesurgeriesTable 2 Summary of study surgeriesPractice 1RegisteredpatientsNumberof GPsPatientCharacteristics1 10600 6

Mixed income70 white2 - -Low incomeMainly white3 11500 6Middle incomeMainly white4 - -Low income50 white5 14400 9Mixed income70 white6 6450 3Mixed incomeMainly whiteNB Practices 1 and 2 have two locations as do Practices 3 and 4

A Research Fellow (RF) of the University of Warwick recruited patients in the waitingrooms of the four surgeries The timing of recruiting visits to the surgeries wasvaried The routine nature of the recruitment meant that study participants werethose who normally attend general practice A total of 334 participants successfullycompleted the GPPAQ and a total of 258 participants completed it again a weeklater The PAI category allocated to each individual resulting from the completion ofthe second GPPAQ was compared with allocation to a physical activity categoryresulting from analysis of activity recorded for the same individual during thepreceding week using an Actigraph motion sensor Demographic characteristics ofparticipants who completed the first GPPAQ are summarised in Table 2Table 3 Participant characteristicsN GenderMaleFemale109223328672Age group18-2425-3435-4445-5455-6465-74226167746543

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

cycling (hrwk)Sedentary Standing Physical Heavy Manual0 Inactive ModeratelyInactiveModeratelyActiveActiveSome but lt 1 ModeratelyInactiveModeratelyActiveActive Active1-29 ModeratelyActiveActive Active Activege 3 Active Active Active Active1 3C COMBINING RESPONSES FOR PHYSICAL EXERCISE AND CYCLINGCyclingPhysicalExercise0 Some but lt 1 1-29 ge30 0 Some but lt 1 1-29 ge3Some but lt 1 Some but lt 1 1-29 ge3 ge31-29 1-29 ge3 ge3 ge3ge3 ge3 ge3 ge3 ge3D GPPAQ READ CODES4 Byte Version 2 CTV3138X | GPPAQphyscl act indinactive138X | Generalpractice physicalactivity questionnairephysical activityindex inactiveXaPP8 | General practicephysical activityquestionnaire physicalactivity index inactive366121000000108 | General practicephysical activity questionnaire physicalactivity index inactive (finding)138Y | GPPAQphys act ind modinactv138Y | Generalpractice physicalactivity questionnairephysical activityindex moderatelyinactiveXaPPB | General practicephysical activityquestionnaire physicalactivity index moderately

inactive366171000000107 | General practicephysical activity questionnaire physicalactivity index moderately inactive(finding)138a | GPPAQphys act ind modactive138a | Generalpractice physicalactivity questionnairephysical activityindex moderatelyactiveXaPPD | General practicephysical activityquestionnaire physicalactivity index moderatelyactive366211000000105 | General practicephysical activity questionnaire physicalactivity index moderately active(finding)138b | GPPAQphysical act indactive138b | Generalpractice physicalactivity questionnairephysical activityindex activeXaPPE | General practicephysical activityquestionnaire physicalactivity index active366241000000106 | General practicephysical activity questionnaire physicalactivity index active (finding)1 4ANNEX 2A AN EXAMPLE OF A MOTIVATIONAL INTERVIEW WITHIN APHYSICAL ACTIVITY BRIEF INTERVENTIONPractitioners can consider the following example of a brief verbal intervention forInactive patients based on the principles of Motivational Interviewing (MI)Any intervention should be consistent with the agenda on patient led consultations andchoice One way to do this is to base behaviour-change negotiations on the principles ofmotivational interviewing (MI) Although developed in the field of addictions brief versions ofMI have been adapted and applied to a wide variety of behaviours and conditions such assmoking diet physical activity medical adherence and diabetes with evidence ofeffectiveness (Resnicow et al 2002 Rollnick 1999 Rubak 2005)Motivational Interviewing elicits change talk in the patient empowering them tochange their own behaviour Below are example questions for an MI based dialogueExample Dialogue for Inactive PatientsQuestion set OneldquoOn a scale from 0 to 10 where 0 is not important at all and 10 is extremely

important how important is getting more active for yourdquoldquoWhy did you pick this numberldquoldquoWhy did you not pick a lower numberldquoldquoWhat would you need to do to get you to a higher numberrdquoQuestion set TwoldquoNow think about why you want to do this Think about how yoursquoll feel whatyoursquoll look like what yoursquoll be able to do that you canrsquot do now Also thinkabout what might be stopping you from changing and what will happen if youdonrsquotrdquoWhy you want to changeeg To be able to play with children grandchildren To help healthWhat will happen if you changeeg more energy less lonely control conditionWhy you donrsquot want to changeeg low confidence donrsquot think will enjoy itWhat will happen if you donrsquoteg condition will get worse feel bad about self not be able to play withchildrengrandchildrenQuestion set ThreelsquoIf you were to decide to increase your physical activity how confident areyou that you would succeed If on a scale of 0 to 10 0 means that you are1 5not at all confident and 10 means that you are 100 confident you couldbecome more active What number would you give yourselfrdquoWhy did you pick this number on the scaleWhy did you not pick a lower numberWhat would you need to do to get a higher numberAll the while yoursquore trying elicit change talk from them and reaffirm these statementsback to the patientFinally provide the patient with a brief summary of what you heard and then askldquoWhat do you think the next step is for yourdquoYou can talk about the patients day and work with the patient about when activitycould be built in eg getting off the bus a stop early or walking children to schoolAnd also talk about activities that might be of interest to the patient whether itrsquosgardening dance swimming cycling walking or footballA common response is for the patient to say they donrsquot know or are uncertain If theydo follow withldquoLetrsquos list what the options are at the moment You couldStay as you are and do nothingStart to increase the amount of physical activity that you dordquoAgain this should illicit change talkGo through the patients day with them and talk about when activity could bebuilt in eg getting off the bus a stop early joining in a health walk or walkingthe children to schoolAlso talk about what activities might be of interest to them signpost to localactivities from gardening to dance to footballAsk the patient what they make of these opportunitiesIf interested talk to the patient about appropriate levels of activity and how tobuild up their activity levels If someone hasnrsquot been active for a long timegoing straight into vigorous activity isnrsquot a good idea advise patients to build

up their activity levels and intensity graduallyEncourage a patient to set a specific goal such asldquoI will go for a walk on Tuesday at lunchtime at the park for thirty minutes If Icanrsquot make it then I will go on WednesdayrdquoIn just a few minutes it is possible to encourage the patient to consider why and howthey might change their physical activity without feeling as if they are being pushedor coerced into something they are not ready for(Dialogue based on Rollnick et al 1997 Miller 2005 Rollnick et al 2005)1 6B ASSESSING INACTIVE PATIENTS WHO SELF REPORT 3 HOURSOR MORE PER WEEK OF WALKINGPatients who fall within the inactive category but claim to undertake significantamounts of walking may require a modified brief intervention that probes theirunderstanding of walking and walking pace and the basis upon which they havedeclared the amount of walking accumulated during the last week For those patientswho remain confident that they achieve the recommended levels of physical activityby virtue of their walking intensity and duration encourage them to continue Theexample dialogue given for Inactive patients could be prefaced with the followingldquoYou say you do three hours or more of walking per week So that I mightbetter understand how walking fits into your day perhaps you could talk methrough a typical day for you starting from when you get up in the morningright through to when you go to bed telling me where walking fits in Howabout yesterday could you talk me through yesterdayrdquoIf the patient insists the previous day was atypical use the day before that Try toavoid going too far back as the accuracy of recall will be diminished Thepractitionerrsquos task in this exercise is simply to listen without offering any judgementof what is being said This is not further assessment of the patientrsquos activity The aimis to get the patient talking about their current behaviour in a non-threatening (thethreat of being told to change) environment that will build rapport and conveys to thepatient that the practitioner listens and is genuinely interested in their situationEnsure you assess the level of intensity of walking you can use the following tool toassess intensity0 breathing easily conversation is easy1 breathing lightly and talking easily but heart rate increases2 still talking comfortably but breathing more quickly body warming up3 breathing more deeply and harder talking with a little more difficulty4 breathing very hard and short of breath cannot carry on a conversationLight Activity 0-1 Moderate Activity 2-3 Vigorous Activity 4Patients should be hitting 2-3 for the walking to count towards their activity levelOnce the patient has completed the description of their day the practitioner shouldsimply summarise the information on walking and then proceed to the motivation andconfidence questions described above as appropriate1 7ANNEX 3 GPPAQ TECHNICAL BACKGROUND AND EVALUATIONIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivityThe measure was intended for use in routine general practice and its purpose was toprovide a simple 4-level Physical Activity Index (PAI) reflecting an individualrsquos currentphysical activity The index would be used to decide when interventions to increase

physical activity might be appropriate A working title for the measure was theGeneral Practice Physical Activity Questionnaire (GPPAQ)After reviewing the literature and consultation with experts performancerequirements for the GPPAQ were agreed These were thatbull The method of completion should be self explanatorybull It should be designed for use by adults aged 18-74 years (later revised to 16-74 years)bull It should be possible for respondents to complete the questionnaire withoutassistancebull It should take less than one minute to completebull Individual physical activity categories should be simple requiring limitedcomputationbull The physical activity categories should allow for the assignment of a physicalactivity Read Codebull The output of the questionnaire should enable practice staff to make adecision on whether the patient concerned should be advised to be moreactive or whether more detailed assessment was requiredAlthough no existing self-report measure of physical activity had specifically beendeveloped for routine general practice a short physical activity questionnaire used inthe European Prospective Investigation into Cancer (EPIC) met many of the criteriaand a simple index of physical activity could be derived It had establishedacceptable levels of repeatability and validity in a sample of English adults aged 40-65 years (Wareham et al 2002) It was decided that this short questionnaire shouldform the basis of the new measureA pilot study was conducted in three general practices with practice nursesadministering the self-completion of GPPAQ to 61 patients from a variety of newlyregistered patients including a number of patients for whom English was not the firstlanguage The GPPAQ was well received by nurses patients and generalpractitioners Practitioners welcomed a simple and efficient way of assessingphysical activity In particular they were keen to have a standardised way ofassigning Read Codes for physical activity The patients did not experience anyproblems in completing the questionnaire even when English was not the firstlanguageThe pilot study was limited to new registration appointments but most practitionerssuggested other possible uses for the GPPAQ including hypertension and diabetesclinics1 8Due to the positive findings of the pilot study a further study was conducted toexamine how reliable and accurate the GPPAQ was in routine general practice Foursurgeries were recruited in Coventry West Midlands Table 2 summarises thesurgeriesTable 2 Summary of study surgeriesPractice 1RegisteredpatientsNumberof GPsPatientCharacteristics1 10600 6

Mixed income70 white2 - -Low incomeMainly white3 11500 6Middle incomeMainly white4 - -Low income50 white5 14400 9Mixed income70 white6 6450 3Mixed incomeMainly whiteNB Practices 1 and 2 have two locations as do Practices 3 and 4

A Research Fellow (RF) of the University of Warwick recruited patients in the waitingrooms of the four surgeries The timing of recruiting visits to the surgeries wasvaried The routine nature of the recruitment meant that study participants werethose who normally attend general practice A total of 334 participants successfullycompleted the GPPAQ and a total of 258 participants completed it again a weeklater The PAI category allocated to each individual resulting from the completion ofthe second GPPAQ was compared with allocation to a physical activity categoryresulting from analysis of activity recorded for the same individual during thepreceding week using an Actigraph motion sensor Demographic characteristics ofparticipants who completed the first GPPAQ are summarised in Table 2Table 3 Participant characteristicsN GenderMaleFemale109223328672Age group18-2425-3435-4445-5455-6465-74226167746543

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

inactive366171000000107 | General practicephysical activity questionnaire physicalactivity index moderately inactive(finding)138a | GPPAQphys act ind modactive138a | Generalpractice physicalactivity questionnairephysical activityindex moderatelyactiveXaPPD | General practicephysical activityquestionnaire physicalactivity index moderatelyactive366211000000105 | General practicephysical activity questionnaire physicalactivity index moderately active(finding)138b | GPPAQphysical act indactive138b | Generalpractice physicalactivity questionnairephysical activityindex activeXaPPE | General practicephysical activityquestionnaire physicalactivity index active366241000000106 | General practicephysical activity questionnaire physicalactivity index active (finding)1 4ANNEX 2A AN EXAMPLE OF A MOTIVATIONAL INTERVIEW WITHIN APHYSICAL ACTIVITY BRIEF INTERVENTIONPractitioners can consider the following example of a brief verbal intervention forInactive patients based on the principles of Motivational Interviewing (MI)Any intervention should be consistent with the agenda on patient led consultations andchoice One way to do this is to base behaviour-change negotiations on the principles ofmotivational interviewing (MI) Although developed in the field of addictions brief versions ofMI have been adapted and applied to a wide variety of behaviours and conditions such assmoking diet physical activity medical adherence and diabetes with evidence ofeffectiveness (Resnicow et al 2002 Rollnick 1999 Rubak 2005)Motivational Interviewing elicits change talk in the patient empowering them tochange their own behaviour Below are example questions for an MI based dialogueExample Dialogue for Inactive PatientsQuestion set OneldquoOn a scale from 0 to 10 where 0 is not important at all and 10 is extremely

important how important is getting more active for yourdquoldquoWhy did you pick this numberldquoldquoWhy did you not pick a lower numberldquoldquoWhat would you need to do to get you to a higher numberrdquoQuestion set TwoldquoNow think about why you want to do this Think about how yoursquoll feel whatyoursquoll look like what yoursquoll be able to do that you canrsquot do now Also thinkabout what might be stopping you from changing and what will happen if youdonrsquotrdquoWhy you want to changeeg To be able to play with children grandchildren To help healthWhat will happen if you changeeg more energy less lonely control conditionWhy you donrsquot want to changeeg low confidence donrsquot think will enjoy itWhat will happen if you donrsquoteg condition will get worse feel bad about self not be able to play withchildrengrandchildrenQuestion set ThreelsquoIf you were to decide to increase your physical activity how confident areyou that you would succeed If on a scale of 0 to 10 0 means that you are1 5not at all confident and 10 means that you are 100 confident you couldbecome more active What number would you give yourselfrdquoWhy did you pick this number on the scaleWhy did you not pick a lower numberWhat would you need to do to get a higher numberAll the while yoursquore trying elicit change talk from them and reaffirm these statementsback to the patientFinally provide the patient with a brief summary of what you heard and then askldquoWhat do you think the next step is for yourdquoYou can talk about the patients day and work with the patient about when activitycould be built in eg getting off the bus a stop early or walking children to schoolAnd also talk about activities that might be of interest to the patient whether itrsquosgardening dance swimming cycling walking or footballA common response is for the patient to say they donrsquot know or are uncertain If theydo follow withldquoLetrsquos list what the options are at the moment You couldStay as you are and do nothingStart to increase the amount of physical activity that you dordquoAgain this should illicit change talkGo through the patients day with them and talk about when activity could bebuilt in eg getting off the bus a stop early joining in a health walk or walkingthe children to schoolAlso talk about what activities might be of interest to them signpost to localactivities from gardening to dance to footballAsk the patient what they make of these opportunitiesIf interested talk to the patient about appropriate levels of activity and how tobuild up their activity levels If someone hasnrsquot been active for a long timegoing straight into vigorous activity isnrsquot a good idea advise patients to build

up their activity levels and intensity graduallyEncourage a patient to set a specific goal such asldquoI will go for a walk on Tuesday at lunchtime at the park for thirty minutes If Icanrsquot make it then I will go on WednesdayrdquoIn just a few minutes it is possible to encourage the patient to consider why and howthey might change their physical activity without feeling as if they are being pushedor coerced into something they are not ready for(Dialogue based on Rollnick et al 1997 Miller 2005 Rollnick et al 2005)1 6B ASSESSING INACTIVE PATIENTS WHO SELF REPORT 3 HOURSOR MORE PER WEEK OF WALKINGPatients who fall within the inactive category but claim to undertake significantamounts of walking may require a modified brief intervention that probes theirunderstanding of walking and walking pace and the basis upon which they havedeclared the amount of walking accumulated during the last week For those patientswho remain confident that they achieve the recommended levels of physical activityby virtue of their walking intensity and duration encourage them to continue Theexample dialogue given for Inactive patients could be prefaced with the followingldquoYou say you do three hours or more of walking per week So that I mightbetter understand how walking fits into your day perhaps you could talk methrough a typical day for you starting from when you get up in the morningright through to when you go to bed telling me where walking fits in Howabout yesterday could you talk me through yesterdayrdquoIf the patient insists the previous day was atypical use the day before that Try toavoid going too far back as the accuracy of recall will be diminished Thepractitionerrsquos task in this exercise is simply to listen without offering any judgementof what is being said This is not further assessment of the patientrsquos activity The aimis to get the patient talking about their current behaviour in a non-threatening (thethreat of being told to change) environment that will build rapport and conveys to thepatient that the practitioner listens and is genuinely interested in their situationEnsure you assess the level of intensity of walking you can use the following tool toassess intensity0 breathing easily conversation is easy1 breathing lightly and talking easily but heart rate increases2 still talking comfortably but breathing more quickly body warming up3 breathing more deeply and harder talking with a little more difficulty4 breathing very hard and short of breath cannot carry on a conversationLight Activity 0-1 Moderate Activity 2-3 Vigorous Activity 4Patients should be hitting 2-3 for the walking to count towards their activity levelOnce the patient has completed the description of their day the practitioner shouldsimply summarise the information on walking and then proceed to the motivation andconfidence questions described above as appropriate1 7ANNEX 3 GPPAQ TECHNICAL BACKGROUND AND EVALUATIONIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivityThe measure was intended for use in routine general practice and its purpose was toprovide a simple 4-level Physical Activity Index (PAI) reflecting an individualrsquos currentphysical activity The index would be used to decide when interventions to increase

physical activity might be appropriate A working title for the measure was theGeneral Practice Physical Activity Questionnaire (GPPAQ)After reviewing the literature and consultation with experts performancerequirements for the GPPAQ were agreed These were thatbull The method of completion should be self explanatorybull It should be designed for use by adults aged 18-74 years (later revised to 16-74 years)bull It should be possible for respondents to complete the questionnaire withoutassistancebull It should take less than one minute to completebull Individual physical activity categories should be simple requiring limitedcomputationbull The physical activity categories should allow for the assignment of a physicalactivity Read Codebull The output of the questionnaire should enable practice staff to make adecision on whether the patient concerned should be advised to be moreactive or whether more detailed assessment was requiredAlthough no existing self-report measure of physical activity had specifically beendeveloped for routine general practice a short physical activity questionnaire used inthe European Prospective Investigation into Cancer (EPIC) met many of the criteriaand a simple index of physical activity could be derived It had establishedacceptable levels of repeatability and validity in a sample of English adults aged 40-65 years (Wareham et al 2002) It was decided that this short questionnaire shouldform the basis of the new measureA pilot study was conducted in three general practices with practice nursesadministering the self-completion of GPPAQ to 61 patients from a variety of newlyregistered patients including a number of patients for whom English was not the firstlanguage The GPPAQ was well received by nurses patients and generalpractitioners Practitioners welcomed a simple and efficient way of assessingphysical activity In particular they were keen to have a standardised way ofassigning Read Codes for physical activity The patients did not experience anyproblems in completing the questionnaire even when English was not the firstlanguageThe pilot study was limited to new registration appointments but most practitionerssuggested other possible uses for the GPPAQ including hypertension and diabetesclinics1 8Due to the positive findings of the pilot study a further study was conducted toexamine how reliable and accurate the GPPAQ was in routine general practice Foursurgeries were recruited in Coventry West Midlands Table 2 summarises thesurgeriesTable 2 Summary of study surgeriesPractice 1RegisteredpatientsNumberof GPsPatientCharacteristics1 10600 6

Mixed income70 white2 - -Low incomeMainly white3 11500 6Middle incomeMainly white4 - -Low income50 white5 14400 9Mixed income70 white6 6450 3Mixed incomeMainly whiteNB Practices 1 and 2 have two locations as do Practices 3 and 4

A Research Fellow (RF) of the University of Warwick recruited patients in the waitingrooms of the four surgeries The timing of recruiting visits to the surgeries wasvaried The routine nature of the recruitment meant that study participants werethose who normally attend general practice A total of 334 participants successfullycompleted the GPPAQ and a total of 258 participants completed it again a weeklater The PAI category allocated to each individual resulting from the completion ofthe second GPPAQ was compared with allocation to a physical activity categoryresulting from analysis of activity recorded for the same individual during thepreceding week using an Actigraph motion sensor Demographic characteristics ofparticipants who completed the first GPPAQ are summarised in Table 2Table 3 Participant characteristicsN GenderMaleFemale109223328672Age group18-2425-3435-4445-5455-6465-74226167746543

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

important how important is getting more active for yourdquoldquoWhy did you pick this numberldquoldquoWhy did you not pick a lower numberldquoldquoWhat would you need to do to get you to a higher numberrdquoQuestion set TwoldquoNow think about why you want to do this Think about how yoursquoll feel whatyoursquoll look like what yoursquoll be able to do that you canrsquot do now Also thinkabout what might be stopping you from changing and what will happen if youdonrsquotrdquoWhy you want to changeeg To be able to play with children grandchildren To help healthWhat will happen if you changeeg more energy less lonely control conditionWhy you donrsquot want to changeeg low confidence donrsquot think will enjoy itWhat will happen if you donrsquoteg condition will get worse feel bad about self not be able to play withchildrengrandchildrenQuestion set ThreelsquoIf you were to decide to increase your physical activity how confident areyou that you would succeed If on a scale of 0 to 10 0 means that you are1 5not at all confident and 10 means that you are 100 confident you couldbecome more active What number would you give yourselfrdquoWhy did you pick this number on the scaleWhy did you not pick a lower numberWhat would you need to do to get a higher numberAll the while yoursquore trying elicit change talk from them and reaffirm these statementsback to the patientFinally provide the patient with a brief summary of what you heard and then askldquoWhat do you think the next step is for yourdquoYou can talk about the patients day and work with the patient about when activitycould be built in eg getting off the bus a stop early or walking children to schoolAnd also talk about activities that might be of interest to the patient whether itrsquosgardening dance swimming cycling walking or footballA common response is for the patient to say they donrsquot know or are uncertain If theydo follow withldquoLetrsquos list what the options are at the moment You couldStay as you are and do nothingStart to increase the amount of physical activity that you dordquoAgain this should illicit change talkGo through the patients day with them and talk about when activity could bebuilt in eg getting off the bus a stop early joining in a health walk or walkingthe children to schoolAlso talk about what activities might be of interest to them signpost to localactivities from gardening to dance to footballAsk the patient what they make of these opportunitiesIf interested talk to the patient about appropriate levels of activity and how tobuild up their activity levels If someone hasnrsquot been active for a long timegoing straight into vigorous activity isnrsquot a good idea advise patients to build

up their activity levels and intensity graduallyEncourage a patient to set a specific goal such asldquoI will go for a walk on Tuesday at lunchtime at the park for thirty minutes If Icanrsquot make it then I will go on WednesdayrdquoIn just a few minutes it is possible to encourage the patient to consider why and howthey might change their physical activity without feeling as if they are being pushedor coerced into something they are not ready for(Dialogue based on Rollnick et al 1997 Miller 2005 Rollnick et al 2005)1 6B ASSESSING INACTIVE PATIENTS WHO SELF REPORT 3 HOURSOR MORE PER WEEK OF WALKINGPatients who fall within the inactive category but claim to undertake significantamounts of walking may require a modified brief intervention that probes theirunderstanding of walking and walking pace and the basis upon which they havedeclared the amount of walking accumulated during the last week For those patientswho remain confident that they achieve the recommended levels of physical activityby virtue of their walking intensity and duration encourage them to continue Theexample dialogue given for Inactive patients could be prefaced with the followingldquoYou say you do three hours or more of walking per week So that I mightbetter understand how walking fits into your day perhaps you could talk methrough a typical day for you starting from when you get up in the morningright through to when you go to bed telling me where walking fits in Howabout yesterday could you talk me through yesterdayrdquoIf the patient insists the previous day was atypical use the day before that Try toavoid going too far back as the accuracy of recall will be diminished Thepractitionerrsquos task in this exercise is simply to listen without offering any judgementof what is being said This is not further assessment of the patientrsquos activity The aimis to get the patient talking about their current behaviour in a non-threatening (thethreat of being told to change) environment that will build rapport and conveys to thepatient that the practitioner listens and is genuinely interested in their situationEnsure you assess the level of intensity of walking you can use the following tool toassess intensity0 breathing easily conversation is easy1 breathing lightly and talking easily but heart rate increases2 still talking comfortably but breathing more quickly body warming up3 breathing more deeply and harder talking with a little more difficulty4 breathing very hard and short of breath cannot carry on a conversationLight Activity 0-1 Moderate Activity 2-3 Vigorous Activity 4Patients should be hitting 2-3 for the walking to count towards their activity levelOnce the patient has completed the description of their day the practitioner shouldsimply summarise the information on walking and then proceed to the motivation andconfidence questions described above as appropriate1 7ANNEX 3 GPPAQ TECHNICAL BACKGROUND AND EVALUATIONIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivityThe measure was intended for use in routine general practice and its purpose was toprovide a simple 4-level Physical Activity Index (PAI) reflecting an individualrsquos currentphysical activity The index would be used to decide when interventions to increase

physical activity might be appropriate A working title for the measure was theGeneral Practice Physical Activity Questionnaire (GPPAQ)After reviewing the literature and consultation with experts performancerequirements for the GPPAQ were agreed These were thatbull The method of completion should be self explanatorybull It should be designed for use by adults aged 18-74 years (later revised to 16-74 years)bull It should be possible for respondents to complete the questionnaire withoutassistancebull It should take less than one minute to completebull Individual physical activity categories should be simple requiring limitedcomputationbull The physical activity categories should allow for the assignment of a physicalactivity Read Codebull The output of the questionnaire should enable practice staff to make adecision on whether the patient concerned should be advised to be moreactive or whether more detailed assessment was requiredAlthough no existing self-report measure of physical activity had specifically beendeveloped for routine general practice a short physical activity questionnaire used inthe European Prospective Investigation into Cancer (EPIC) met many of the criteriaand a simple index of physical activity could be derived It had establishedacceptable levels of repeatability and validity in a sample of English adults aged 40-65 years (Wareham et al 2002) It was decided that this short questionnaire shouldform the basis of the new measureA pilot study was conducted in three general practices with practice nursesadministering the self-completion of GPPAQ to 61 patients from a variety of newlyregistered patients including a number of patients for whom English was not the firstlanguage The GPPAQ was well received by nurses patients and generalpractitioners Practitioners welcomed a simple and efficient way of assessingphysical activity In particular they were keen to have a standardised way ofassigning Read Codes for physical activity The patients did not experience anyproblems in completing the questionnaire even when English was not the firstlanguageThe pilot study was limited to new registration appointments but most practitionerssuggested other possible uses for the GPPAQ including hypertension and diabetesclinics1 8Due to the positive findings of the pilot study a further study was conducted toexamine how reliable and accurate the GPPAQ was in routine general practice Foursurgeries were recruited in Coventry West Midlands Table 2 summarises thesurgeriesTable 2 Summary of study surgeriesPractice 1RegisteredpatientsNumberof GPsPatientCharacteristics1 10600 6

Mixed income70 white2 - -Low incomeMainly white3 11500 6Middle incomeMainly white4 - -Low income50 white5 14400 9Mixed income70 white6 6450 3Mixed incomeMainly whiteNB Practices 1 and 2 have two locations as do Practices 3 and 4

A Research Fellow (RF) of the University of Warwick recruited patients in the waitingrooms of the four surgeries The timing of recruiting visits to the surgeries wasvaried The routine nature of the recruitment meant that study participants werethose who normally attend general practice A total of 334 participants successfullycompleted the GPPAQ and a total of 258 participants completed it again a weeklater The PAI category allocated to each individual resulting from the completion ofthe second GPPAQ was compared with allocation to a physical activity categoryresulting from analysis of activity recorded for the same individual during thepreceding week using an Actigraph motion sensor Demographic characteristics ofparticipants who completed the first GPPAQ are summarised in Table 2Table 3 Participant characteristicsN GenderMaleFemale109223328672Age group18-2425-3435-4445-5455-6465-74226167746543

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

up their activity levels and intensity graduallyEncourage a patient to set a specific goal such asldquoI will go for a walk on Tuesday at lunchtime at the park for thirty minutes If Icanrsquot make it then I will go on WednesdayrdquoIn just a few minutes it is possible to encourage the patient to consider why and howthey might change their physical activity without feeling as if they are being pushedor coerced into something they are not ready for(Dialogue based on Rollnick et al 1997 Miller 2005 Rollnick et al 2005)1 6B ASSESSING INACTIVE PATIENTS WHO SELF REPORT 3 HOURSOR MORE PER WEEK OF WALKINGPatients who fall within the inactive category but claim to undertake significantamounts of walking may require a modified brief intervention that probes theirunderstanding of walking and walking pace and the basis upon which they havedeclared the amount of walking accumulated during the last week For those patientswho remain confident that they achieve the recommended levels of physical activityby virtue of their walking intensity and duration encourage them to continue Theexample dialogue given for Inactive patients could be prefaced with the followingldquoYou say you do three hours or more of walking per week So that I mightbetter understand how walking fits into your day perhaps you could talk methrough a typical day for you starting from when you get up in the morningright through to when you go to bed telling me where walking fits in Howabout yesterday could you talk me through yesterdayrdquoIf the patient insists the previous day was atypical use the day before that Try toavoid going too far back as the accuracy of recall will be diminished Thepractitionerrsquos task in this exercise is simply to listen without offering any judgementof what is being said This is not further assessment of the patientrsquos activity The aimis to get the patient talking about their current behaviour in a non-threatening (thethreat of being told to change) environment that will build rapport and conveys to thepatient that the practitioner listens and is genuinely interested in their situationEnsure you assess the level of intensity of walking you can use the following tool toassess intensity0 breathing easily conversation is easy1 breathing lightly and talking easily but heart rate increases2 still talking comfortably but breathing more quickly body warming up3 breathing more deeply and harder talking with a little more difficulty4 breathing very hard and short of breath cannot carry on a conversationLight Activity 0-1 Moderate Activity 2-3 Vigorous Activity 4Patients should be hitting 2-3 for the walking to count towards their activity levelOnce the patient has completed the description of their day the practitioner shouldsimply summarise the information on walking and then proceed to the motivation andconfidence questions described above as appropriate1 7ANNEX 3 GPPAQ TECHNICAL BACKGROUND AND EVALUATIONIn 2002 the Department of Health commissioned researchers from the LondonSchool of Hygiene amp Tropical Medicine to produce a short measure of physicalactivityThe measure was intended for use in routine general practice and its purpose was toprovide a simple 4-level Physical Activity Index (PAI) reflecting an individualrsquos currentphysical activity The index would be used to decide when interventions to increase

physical activity might be appropriate A working title for the measure was theGeneral Practice Physical Activity Questionnaire (GPPAQ)After reviewing the literature and consultation with experts performancerequirements for the GPPAQ were agreed These were thatbull The method of completion should be self explanatorybull It should be designed for use by adults aged 18-74 years (later revised to 16-74 years)bull It should be possible for respondents to complete the questionnaire withoutassistancebull It should take less than one minute to completebull Individual physical activity categories should be simple requiring limitedcomputationbull The physical activity categories should allow for the assignment of a physicalactivity Read Codebull The output of the questionnaire should enable practice staff to make adecision on whether the patient concerned should be advised to be moreactive or whether more detailed assessment was requiredAlthough no existing self-report measure of physical activity had specifically beendeveloped for routine general practice a short physical activity questionnaire used inthe European Prospective Investigation into Cancer (EPIC) met many of the criteriaand a simple index of physical activity could be derived It had establishedacceptable levels of repeatability and validity in a sample of English adults aged 40-65 years (Wareham et al 2002) It was decided that this short questionnaire shouldform the basis of the new measureA pilot study was conducted in three general practices with practice nursesadministering the self-completion of GPPAQ to 61 patients from a variety of newlyregistered patients including a number of patients for whom English was not the firstlanguage The GPPAQ was well received by nurses patients and generalpractitioners Practitioners welcomed a simple and efficient way of assessingphysical activity In particular they were keen to have a standardised way ofassigning Read Codes for physical activity The patients did not experience anyproblems in completing the questionnaire even when English was not the firstlanguageThe pilot study was limited to new registration appointments but most practitionerssuggested other possible uses for the GPPAQ including hypertension and diabetesclinics1 8Due to the positive findings of the pilot study a further study was conducted toexamine how reliable and accurate the GPPAQ was in routine general practice Foursurgeries were recruited in Coventry West Midlands Table 2 summarises thesurgeriesTable 2 Summary of study surgeriesPractice 1RegisteredpatientsNumberof GPsPatientCharacteristics1 10600 6

Mixed income70 white2 - -Low incomeMainly white3 11500 6Middle incomeMainly white4 - -Low income50 white5 14400 9Mixed income70 white6 6450 3Mixed incomeMainly whiteNB Practices 1 and 2 have two locations as do Practices 3 and 4

A Research Fellow (RF) of the University of Warwick recruited patients in the waitingrooms of the four surgeries The timing of recruiting visits to the surgeries wasvaried The routine nature of the recruitment meant that study participants werethose who normally attend general practice A total of 334 participants successfullycompleted the GPPAQ and a total of 258 participants completed it again a weeklater The PAI category allocated to each individual resulting from the completion ofthe second GPPAQ was compared with allocation to a physical activity categoryresulting from analysis of activity recorded for the same individual during thepreceding week using an Actigraph motion sensor Demographic characteristics ofparticipants who completed the first GPPAQ are summarised in Table 2Table 3 Participant characteristicsN GenderMaleFemale109223328672Age group18-2425-3435-4445-5455-6465-74226167746543

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

physical activity might be appropriate A working title for the measure was theGeneral Practice Physical Activity Questionnaire (GPPAQ)After reviewing the literature and consultation with experts performancerequirements for the GPPAQ were agreed These were thatbull The method of completion should be self explanatorybull It should be designed for use by adults aged 18-74 years (later revised to 16-74 years)bull It should be possible for respondents to complete the questionnaire withoutassistancebull It should take less than one minute to completebull Individual physical activity categories should be simple requiring limitedcomputationbull The physical activity categories should allow for the assignment of a physicalactivity Read Codebull The output of the questionnaire should enable practice staff to make adecision on whether the patient concerned should be advised to be moreactive or whether more detailed assessment was requiredAlthough no existing self-report measure of physical activity had specifically beendeveloped for routine general practice a short physical activity questionnaire used inthe European Prospective Investigation into Cancer (EPIC) met many of the criteriaand a simple index of physical activity could be derived It had establishedacceptable levels of repeatability and validity in a sample of English adults aged 40-65 years (Wareham et al 2002) It was decided that this short questionnaire shouldform the basis of the new measureA pilot study was conducted in three general practices with practice nursesadministering the self-completion of GPPAQ to 61 patients from a variety of newlyregistered patients including a number of patients for whom English was not the firstlanguage The GPPAQ was well received by nurses patients and generalpractitioners Practitioners welcomed a simple and efficient way of assessingphysical activity In particular they were keen to have a standardised way ofassigning Read Codes for physical activity The patients did not experience anyproblems in completing the questionnaire even when English was not the firstlanguageThe pilot study was limited to new registration appointments but most practitionerssuggested other possible uses for the GPPAQ including hypertension and diabetesclinics1 8Due to the positive findings of the pilot study a further study was conducted toexamine how reliable and accurate the GPPAQ was in routine general practice Foursurgeries were recruited in Coventry West Midlands Table 2 summarises thesurgeriesTable 2 Summary of study surgeriesPractice 1RegisteredpatientsNumberof GPsPatientCharacteristics1 10600 6

Mixed income70 white2 - -Low incomeMainly white3 11500 6Middle incomeMainly white4 - -Low income50 white5 14400 9Mixed income70 white6 6450 3Mixed incomeMainly whiteNB Practices 1 and 2 have two locations as do Practices 3 and 4

A Research Fellow (RF) of the University of Warwick recruited patients in the waitingrooms of the four surgeries The timing of recruiting visits to the surgeries wasvaried The routine nature of the recruitment meant that study participants werethose who normally attend general practice A total of 334 participants successfullycompleted the GPPAQ and a total of 258 participants completed it again a weeklater The PAI category allocated to each individual resulting from the completion ofthe second GPPAQ was compared with allocation to a physical activity categoryresulting from analysis of activity recorded for the same individual during thepreceding week using an Actigraph motion sensor Demographic characteristics ofparticipants who completed the first GPPAQ are summarised in Table 2Table 3 Participant characteristicsN GenderMaleFemale109223328672Age group18-2425-3435-4445-5455-6465-74226167746543

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

Mixed income70 white2 - -Low incomeMainly white3 11500 6Middle incomeMainly white4 - -Low income50 white5 14400 9Mixed income70 white6 6450 3Mixed incomeMainly whiteNB Practices 1 and 2 have two locations as do Practices 3 and 4

A Research Fellow (RF) of the University of Warwick recruited patients in the waitingrooms of the four surgeries The timing of recruiting visits to the surgeries wasvaried The routine nature of the recruitment meant that study participants werethose who normally attend general practice A total of 334 participants successfullycompleted the GPPAQ and a total of 258 participants completed it again a weeklater The PAI category allocated to each individual resulting from the completion ofthe second GPPAQ was compared with allocation to a physical activity categoryresulting from analysis of activity recorded for the same individual during thepreceding week using an Actigraph motion sensor Demographic characteristics ofparticipants who completed the first GPPAQ are summarised in Table 2Table 3 Participant characteristicsN GenderMaleFemale109223328672Age group18-2425-3435-4445-5455-6465-74226167746543

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

66184202223196130Ethnic groupWhiteNon-white3082492872Body Mass Index(BMI)lt25ge25 to lt 30ge3014312066435365201Excludes missing data

1 9Following the completion of the study the following conclusions can be drawnbull The GPPAQ has good face validity and is acceptable for use in routinegeneral practicebull The GPPAQ has good construct validity- that is the PAI derived from thequestionnaire has the relationship with other measures that we might expect bull The GPPAQ is repeatable - that is a person who had high physical activity ontime 1 tended to have high physical activity on time 2bull The PAI derived from the GPPAQ is taken from the original EPIC study whichhas published criterion validity with positive associations with both daytimeenergy expenditure and cardiorespiratory fitnessbull The PAI derived from the original EPIC questionnaire predicts all-cause andcardio-vascular mortality in men and women The combination of work andleisure time physical activity into a single index are more consistentlyassociated with mortality than either components used alone (Khaw et al Int JEpidemiol 2006)bull The GPPAQ is a simple and lsquoquick to administerrsquo instrument for assessingphysical activity in routine general practice The 4-level PAI derived from theGPPAQ is suitable for ranking an individualrsquos physical activity for the purposeof determining the need for intervention or more detailed assessment and canbe correlated to the existing Read Codes for physical activitybull The GPPAQ was used within the Physical Activity Care Pathway feasibilitypilot as a screening tool prior to the brief intervention practitioners reportedthe questionnaire as taking up to 2 minutes to complete input and analyseThey also had no problems with language barriers easily translating the

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1

questionnaire as and when required2 0ANNEX 4 REFERENCESDepartment of Health (2009) Be Active Be Healthy London Department of HealthDepartment of Health (2000) National Service Framework for CoronaryHeart Disease London Department of HealthDepartment of Health (2004) At least five a week Evidence on the impact ofphysical activity and its relationship to health Department of Health London 2004National Institute for Health and Clinical Excellence Four commonly used methodsto increase physical activity brief interventions in primary care exercise referralschemes pedometers and community-based exercise programmes for walking andcycling ndash Public health Intervention Guidance no2 London National Institute forHealth and Clinical Excellence 2006Khaw KT Jakes R Bingham S Welch A Luben R Day N Wareham N Work andleisure time physical activity assessed using a simple pragmatic validatedquestionnaire and incident cardiovascular and all-cause mortality in men andwomen The European Prospective Investigation into Cancer in Norfolk prospectivepopulation study Int J Epidemiol (2006 in press)Miller WR Enhancing Patient Motivation for Health Behavior ChangeJournal of Cardiopulmonary Rehabilitation 200525207-209Rollnick S Butler CC Stott N Helping smokers make decisions the enhancement ofbrief intervention for general medical practice Patient Education and Counseling1997 31191-203Resnicow K Diiorio C Soet JE Ernst D Borrelli B amp Hecht J Motivationalinterviewing in health promotion it sounds like something is changing HealthPsychology 200221444-451Rollnick S Mason P Butler C (1999) Health Behaviour Change A guide forpractitioners London Churchill LivingstoneRollnick S Butler CC McCambridge J Kinnersley P Elwyn G Resnicow KConsultations about changing behaviour British Medical Journal 2005331961-963Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing asystematic review and meta-analysis Br J Gen Pract 2005 55305ndash312Wareham NJ Jakes RW Renni KL Schuit J Mitchell J Hennings S Day NEValidity and repeatability of a simple index derived from the short physical activityquestionnaire used in the European Prospective Investigation into Cancer andNutrition (EPIC) study Public Health Nutrition 2002 6407-4132 1