There is strong evidence for the use of physical activity to prevent and treat non-communicable diseases. Twenty years ago, Sweden introduced a new method to promote physical activity within healthcare: physical activity on prescription. Today, the Public Health Agency of Sweden coordinates an EU-funded project to support the implementation of the method in nine other European countries.
By Lena Hansson
Insufficient physical activity is one of the leading risk factors for death related to non-communicable diseases (NCDs), such as cardiovascular diseases, cancer, and diabetes. Sweden recognised these problems decades ago in the 80s and 90s, some regions began to prescribe physical activity to patients in primary care. In early 2000, as part of a national effort to promote physical activity in the public, the former Swedish National Institute of Public Health (SNIPH), today the Public Health Agency of Sweden, was responsible for developing a more systematic and evidence-based method to promote physical activity within healthcare. This resulted in Fysisk aktivitet på recept (FaR), in English, Physical activity on prescription (PAP-S).
The uniqueness of PAP-S is the interplay between five core components. Person-centred counselling using diagnosis-specific and evidence-based recommendations of physical activity results in an individualised written prescription accompanied by a follow-up. In addition, the healthcare services collaborate with various activity organisers in the local community to help individuals both increase and maintain their activity level.
PAP-S has shown positive effects on physical activity levels as well as health outcomes in both clinical follow-up studies and randomised controlled trials, and the adherence is as good as to other long-term treatments (1). Follow-up is strongly emphasised in PAP-S, because physical activity behaviour seems to decline with time when there is no structural or regular follow-up. To help make sure that the activity is sustained over the long term, PAP-S emphasises that the prescribed physical activity fits well with the individual’s ordinary life and preferences. For instance, walking may be more suitable than an activity that requires entry cost. An advantage of PAP-S in Sweden is that all licenced health professionals, with adequate expertise, can prescribe physical activity, not only doctors.
In parallel with the work of establishing PAP-S within the healthcare system, the Swedish Professional Association for Physical Activity (YFA), in collaboration with SNIPH, developed an evidence-based handbook on the effects of physical activity for various diseases and diagnoses (Physical Activity in the Prevention and Treatment of Disease, FYSS). The handbook is an essential tool when prescribers recommend physical activity in dialogue with their patients. Activity organisers also use the handbook. YFA updates the FYSS continuously and has protected the trademark FYSS® as well as FaR® to ensure that they are used as intended.
An advantage of PAP-S in Sweden is that all licenced health professionals, with adequate expertise, can prescribe physical activity, not only doctors.
One key factor for the success of PAP-S is the involvement of stakeholders at national, regional and local level. In 2011, the National Board of Health and Welfare launched national guidelines for the prevention of Non-Communicable Diseases. National guidelines help the decision-makers to allocate resources in accordance with the population’s needs. These specific guidelines focus on effective methods for changing patients’ lifestyle habits, including physical activity, and recommends PAP-S. The guidelines were revised and updated 2018 and now emphasise the need for directing the work towards vulnerable groups to tackle health inequalities (3). To support the implementation of recommended methods, the government has reimbursed professional organisations to develop different supporting materials, for example, the Swedish Professional Association for Physical Activity (YFA) and the Swedish Association of Physiotherapists.
A conclusion from early pilot work with PAP-S is the importance of close cooperation between staff in the health sector and staff from the activity organisers, as well as between politicians and healthcare customers. Active ownership is crucial. Management must prioritise the work by allocating economic and personnel resources, and must integrate work on lifestyle and habits in regular healthcare services. It is also important to have clarification of working models, roles and mandates as well as to come to agreements about the collaboration between healthcare and activity organisers. Over the years several research projects, collaborations and networks have established, and a key conclusion is that the method must be adapted to the regional and local circumstances. In recent years, the method has also spread to the specialised, paediatric and school healthcare.
PAP-S has transferred to countries with similar healthcare system and community characteristics like Sweden, that is Iceland and Norway, but also to countries further afield such as Vietnam.
The Public Health Agency of Sweden is coordinating a three-year project to transfer the PAP-S to nine other European countries. The project, ‘A European Physical Activity on Prescription model (EUPAP)’ will run from 2019-2022 and is co-funded by the EU health programme. Sweden is responsible for training courses and supporting materials, while participating countries are responsible for the implementation process. More information about the project and it’s progress can be found at eupap.org.
The EUPAP project “847174/EUPAP” has received funding from the European Union’s Health Programme (2014-2020). The content of this article represents the views of the authors only and is their sole responsibility. It cannot be considered to reflect the views of the European Commission and/or the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA) or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains.
References
- Onerup A, Arvidsson D, Blomqvist A, Daxberg EL, Jivegard L, Jonsdottir IH, et al. Physical activity on prescription in accordance with the Swedish model increases physical activity: a systematic review. Br J Sports Med. 2019;53(6):383-8. DOI:10.1136/bjsports-2018-099598.
- Ref: Kallings LV, Leijon M, Hellenius ML, Stahle A. Physical activity on prescription in primary health care: a follow-up of physical activity level and quality of life. Scand J Med Sci Sports. 2008;18(2):154-61.
- Socialstyrelsen. Nationella riktlinjer för prevention och behandling vid ohälsosamma levnadsvanor. Stöd för styrning och ledning [Internet]. Stockholm: Socialstyrelsen; 2018. [cited 11 October 2019]. Available from: https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/nationella-riktlinjer/2018-6-24.pdf.
Lena Hansson
Lena has previously worked as a programme officer at the Swedish National Board of Health and Welfare, and was involved in the update of the National guidelines for prevention of non-communicable diseases. Lena is part of the EUPAP coordination team.