SUPPORTING HEALTHY MOVEMENT BEHAVIOURS IN PEOPLE WITH METABOLIC RISK, PREDIABETES, OR TYPE 2 DIABETES IN PRIMARY HEALTH CARE

The overall aim of this thesis was to investigate if a pedometer-based intervention in the primary health care setting can support people with prediabetes or type 2 diabetes towards healthier movement behaviours. Moreover, health care professionals’ experiences of supporting people with metabolic risk factors to increase their physical activity were explored. This thesis consists of four papers based on data from two research studies. Paper I, II, and III are based on a randomised controlled trial called the Sophia Step Study, which is a two-year, three-armed pedometer-based intervention. The three groups comprised a multi-component group that received a pedometer and extra counselling, a single-component group that received a pedometer, and a control group that received standard care. The aim of the Sophia Step Study was to support individuals with prediabetes or type 2 diabetes in becoming regularly physically active by reporting their daily number of steps, with or without extra counselling. Paper IV is based on a qualitative interview study that explored nurses’, physicians’, and physiotherapists’ experiences in primary health care when supporting patients with metabolic risk factors to physical activity. In paper I, the effects of self-monitoring steps with or without counselling support for HbA1c, other cardiometabolic risk factors and physical activity during the twoyear intervention were evaluated. In paper II, the effects of the intervention were evaluated on relative time in different movement behaviours. In paper III, predictors associated with intermediate and post intervention increases in steps were explored. Finally, in paper IV, barriers and facilitators perceived by health care professionals who work within Swedish primary care to support people with metabolic risk factors to increase their physical activity were explored. The results show that the Sophia Step Study did not have an effect on the primary outcome HbA1c. However, a significant effect was found for the multi-component group on absolute time in moderate-to-vigorous physical activity during the entire two-year period, as well as for the single-component group at six months. No effect, however, was found for the absolute time in the other movement behaviours, the number of daily steps, any of the biomarkers or the anthropometric variables. Using relative time, instead of absolute time, when evaluating the effect showed a more pronounced effect in all movement behaviours within both intervention groups over the two-year period. At six months, lower number of steps at baseline was a significant predictor for increasing ≥500 steps per day. At 24 months, men, younger participants, and those with higher self-efficacy at baseline had significantly higher odds for increasing ≥500 steps per day. Barriers and facilitators for supporting people with metabolic risk factors in increasing their physical activity, as experienced by nurses, physiotherapists and physicians, were identified at multiple levels, represented by four generic categories: ‘Patient readiness for change’, ‘Supporting the process of change’, ‘The professional role’, and ‘The organisation of primary care’. The overall conclusion is that the self-monitoring of steps with a pedometer seems to be an effective behaviour change technique in maintaining healthy movement behaviours; however, the counselling component of the intervention did not seem to improve the effect. In addition, the intervention did not find evidence for improved metabolic control or improved cardiometabolic risk factors. Moreover, barriers to and facilitators for supporting patients with metabolic risk factors can be found at several levels within primary care, from individual patients and health care professionals to the organisational level. In the primary health care setting, this should be emphasised when implementing support with the intention to increase physical activity in people with metabolic risk factors, prediabetes or type 2 diabetes. List of scientific papers I. Rossen J, Larsson K, Hagströmer M, Yngve A, Brismar K, Ainsworth B, Åberg L, and Johansson U-B. Effects of a three-armed randomised controlled trial using self-monitoring of daily steps with and without counselling in prediabetes and type 2 diabetes-the Sophia Step Study. Int J Behav Nutr Phys Act, 2021, 18(1), 121. doi:10.1186/s12966-021-01193-w II. Larsson K, Von Rosen P, Rossen J, Johansson U, Hagströmer M. Relative time in physical activity and sedentary behaviour across a 2-year pedometerbased intervention in people with prediabetes or type 2 diabetes: a secondary analysis of a randomised controlled trial. JASSB 2, 10 (2023). https://doi.org/10.1186/s44167-023-00020-w III. Larsson K, Rossen J, Norman Å, Johansson U-B, and Hagströmer M. Predictors associated with an increase in daily steps among people with prediabetes or type 2 diabetes participating in a two-year pedometer intervention. Manuscript. IV. Larsson K, Hagströmer M, Rossen J, Johansson U-B, and Norman Å. Health care professionals’ experiences of supporting persons with metabolic risk factors to increase their physical activity level – a qualitative study in primary care. Scand J Prim Health Care, 2023, 1-16. doi:10.1080/02813432.2023. 2187668 All previously published papers were reproduced with permission from the publisher.