INTRODUCTION
Guidelines from the Chief Medical Officers in the UK recommend a goal of 150 minutes per week of moderate-to-vigorous intensity physical activity.1 There is a dose-response relationship between physical activity and prevention of several physical and mental health conditions, and marked health benefits observed with relatively minor levels of physical activity.2,3 However, around 39% of adults are failing to meet UK Government physical activity recommendations.4 The NHS costs attributable to sedentary behaviour in 2016–2017 were £0.7 billion.5
There is a need for effective, low-cost interventions to enhance the adoption and maintenance of regular physical activity as part of an overarching public health strategy. Primary care is well placed to promote physical activity to individuals who may most benefit, and the National Institute for Health and Care Excellence (NICE) recommends that primary care teams deliver tailored, brief, physical activity advice to inactive adults, and follow this up at subsequent appointments.6 Evidence suggests that smaller increases in the physical activity of those who are least active can have a bigger health and cost-effectiveness impact than raising levels of those already slightly active to guideline levels, at a population level.7,8 Healthy inactive adults represent a key population where interventions may be effective in producing sustained changes in physical activity.9
The NHS Long Term Plan emphasises the need to expand social prescribing,10 but there is limited evidence on how general practice can best achieve this. One initiative that is widely available is parkrun. parkrun is a charity that delivers free, weekly 5 km events for all ages, in areas of open space across the UK and other countries. Participants can walk, run, jog, or volunteer. As of May 2020, there are 722 5 km parkruns available to attend across the UK and nearly 1500 registered practices,11 with approximately 170 000 people taking part every weekend, supported by about 16 000 volunteers (https://parkrun.org.uk).
Evidence shows that parkrun is attractive to non-runners,12 with previously inactive people currently making up about 6% of all participants. The recent parkrun Health and Wellbeing Survey showed that parkrun benefits people’s physical and mental health and wellbeing,12,13 including those with long-term conditions such as arthritis, depression, and anxiety.14
The parkrun practice initiative, launched in June 2018 by parkrun and the Royal College of General Practitioners (RCGP), is a widely accessible and low-cost approach in primary care to promoting patient and staff health and wellbeing through increased physical activity and volunteering opportunities.11 It encourages practices to link with their local parkrun events.11,15 Practices can use the parkrun practice Toolkit,11 which offers suggestions and guidance on the types of activities that the practice can undertake, although none are mandatory and creativity is encouraged.
| Primary care has been shown to be successful in promoting physical activity among patients; however, many exercise referrals take place in leisure centres and are only available to the referred patient for a limited time, sometimes with a cost incurred. parkrun has the advantage of addressing some of these limitations. parkrun encourages practices to actively consider the wellbeing needs of their staff, and may also encourage team-building. This study provides evidence of positive experiences with the initiative, which may assist its continued and sustained roll out. |
Evidence is lacking about practices’ motivations for becoming a parkrun practice and the ways in which they engage with and deliver the initiative. In this study, practices’ reasons for, and experiences of, becoming a parkrun practice, the activities they are undertaking, and the challenges they face are investigated. The perceptions of practices who have not registered to become a parkrun practice (non-registered practices) are also explored to understand reasons for non-uptake. These findings will enable researchers to identify ways in which the initiative can be further enhanced for future implementation.
METHOD
A mixed methods study was conducted from April–July 2019. It comprised an online survey of all registered parkrun practices, and interviews and a focus group with practice staff in the West Midlands.
Online survey
Questions (delivered on Qualtrics XM) were devised with input from parkrun Head Office, two parkrun health and wellbeing ambassadors (who are practicing GPs), and the RCGP (the clinical champion for physical activity and lifestyle and Membership Events coordinator). The survey questions were a mixture of tick box (multiple choice), drop-down menu, and free text, and took approximately 10 minutes to complete. It covered practice details, the responder’s role in the initiative, local parkrun details, how the practice became involved, activities delivered, and the process of signposting patients. The survey was piloted by two GP parkrun ambassadors to check for comprehensibility before being distributed. The RCGP National Office emailed the online survey invitation to all 780 designated contacts that had registered with the initiative in April 2019. These included GPs, practice nurses, practice managers, healthcare assistants, and receptionists. A reminder was sent out 2 weeks later to increase the response rate.
Survey data was downloaded into IBM SPSS Statistics (version 26), cleaned, and descriptive statistics were generated for all sections. Free-text comments were categorised and thematically analysed.
Interviews
Purposive sampling of 13 practices was carried out. This comprised nine parkrun practices and four non-registered practices; the latter group were all situated within 3 miles of a parkrun event. These were recruited in the West Midlands, and allowed for comparisons across different parkrun locations and sufficient variance in the ways in which practices may or may not be promoting the initiative. parkrun practices were identified via information on the RCGP website, and non-registered practices using internet sources (for example, Google Maps). A letter was sent by the research team to the practice manager at each practice, followed by an email or telephone call inviting a member of staff to take part in an interview. A larger number of parkrun practices were recruited than non-registered practices, with the aim of achieving data saturation in both groups.
The interview guide was developed by the research team with input from parkrun Head Office and the RCGP, and was informed by the findings from the online survey. The interviews sought to gauge practices’ experiences of, engagement with, and delivery of the initiative, or, if not registered, their views on the initiative.
The interviews were undertaken by two researchers, recorded, transcribed verbatim, and anonymised. NVivo (version 12) was used for data handling and coding. Transcripts were analysed thematically16 by identifying and mapping key themes relevant to the research questions, with the addition of emergent themes. In line with the modified grounded theory method,17 an inductive and deductive approach was taken to the thematic analysis to ensure that the themes were linked to the data collected. The phases of thematic analysis were applied as follows:
familiarising with the data;
generating initial codes;
searching for themes;
reviewing themes;
defining and naming themes; and,
producing the report.
The analysis was carried out between three researchers with subsets of data analysed twice to ensure accuracy in the way in which text was coded.
The quantitative and qualitative data were merged concurrently18 to provide a comprehensive analysis of the research question. Hence, the combined findings are presented thematically.
RESULTS
Of the 780 registered parkrun practices in the UK (April 2019), 306 (39.2%) completed the online survey. Practice and responder characteristics are detailed in Table 1. Not all participants completed all questions, hence differing N-values, for example, where N-values differ from 306, this may be due to the question not being relevant to the responder, or the responder choosing not to answer. Responders were most commonly GPs (n = 175/306, 57.2%) or practice managers (n = 55, 18.0%). There were also responses from practice nurses (n = 19, 6.2%), receptionists (n = 8, 2.6%), and healthcare assistants (n = 5, 1.6%), with some (n = 44, 14.4%) describing themselves as ‘other’. These included pharmacists, social navigators, administrators, and health promotion officers. Most practices (n = 229/305, 75.0%) had a list size >8000 patients. The average list size in the UK is now about 8000 patients.19
Table 1. Practice and responder characteristics
While half of the practices (n = 154/299, 51.5%) had no previous involvement with parkrun prior to registering, most (n = 233/303, 76.9%) responders had been parkrun participants as individuals. Awareness of the initiative had come via the RCGP (n = 107/298, 35.9%), either through direct communication (n = 55/298, 18.5%) or via the RCGP website (n = 52/298, 17.4%). Other channels were parkrun social media (n = 51/298, 17.1%) or a colleague (n = 47/298, 15.8%). The majority of practices (n = 263/294, 89.5%) made the initial contact with their local parkrun, with only 5.8% (n = 17/294) reporting that the parkrun event itself had made the initial contact. Almost all (n = 271/298, 90.9%) were linked with a single parkrun event. For most practices (n = 200/300, 66.7%), the linked parkrun event or closest (if linked with >1) was within their patient catchment area.
Eleven interviews took place over the phone and one face-to-face interview was conducted. At a parkrun event, four staff members from one practice participated in a focus group. The interviewees and focus group participants comprised GPs (n = 6), a GP trainee (n = 1), practice nurses (n = 3), a healthcare assistant (n = 1), and practice managers (n = 5).
Motivation for becoming a parkrun practice
Improving patient health and wellbeing
The strongest motivation for becoming a parkrun practice was ‘improving patient health and wellbeing’, cited by 92.8% (n = 284) (data not shown), and interview data corroborated this:
‘I think as a GP surgery we are forward thinking in terms of social prescribing and want to do more of the preventative measures as opposed to reactive measures […] we want more people to be healthier and live a better, more active lifestyle and obviously this is ideal for that.’
(parkrun practice 4, practice manager)
A strong subtheme was the perception that parkrun gives patients an opportunity to take charge of their own health, rather than relying on medical interventions:
‘I think it’s to do with the idea that health is not just medical, it’s not just in the remit of the medical services to find solutions to health problems, a lot of the solutions might lie in your own lifestyle and trying to get people to be responsible for that.’
(parkrun practice 5, GP)
Raising the profile of the practice and improving staff morale
The positive impact on staff, both in getting involved in the initiative and being more physically active, was another strong motivator, with most responders (n = 222/306, 72.5%) citing ‘improving staff health and wellbeing’, and two-thirds (n = 201, 65.7%) citing ‘improving links with the community’ as reasons for getting involved (data not shown). Some practices (n = 12, 3.9%) also reported ‘other’ factors, which included improving the profile of the practice, competition with other practices, or staff already being involved in the parkrun community (data not shown). Taking part in parkrun together was thought to be good for staff team building as well as a positive way of relieving work-related stress:
‘I think it’s a really nice way of team building and doing something that’s really good […] but I think especially […] general practices are pretty stressful at times and it, it a nice way of having a good down time.’
(parkrun practice 7, GP)
In addition to promoting physical activity, being a parkrun practice encouraged patients and staff to socialise and be part of a local community; of particular significance to those experiencing social isolation or loneliness:
‘I didn’t realise it had a social aspect, that people would stop afterwards and have a cup of tea and catch up. So we could actually use it for patients who are lonely.’
(parkrun practice 9, GP trainee)
Some practices felt that becoming a parkrun practice would position the practice as innovative and quality focussed; thereby strengthening its reputation:
‘I think we’ve always been a relatively innovative practice. We’re ahead of the game in a lot of other areas in terms of, you know, we took on a nurse role in the community. We took our own pharmacist […] and this to me just seemed another natural, sort of, innovation that we could be involved with.’
(parkrun practice 3, GP)
Practice engagement
The importance of there being a motivated parkrunner among practice staff, to catalyse and champion participation in the initiative, was evident. One-third of practices (n = 96/284, 33.8%) commenced activities (such as those suggested in the parkrun practice Toolkit11) in the same month they registered, with some (n = 55/284, 19.4%) beginning the following month. One-quarter (n = 78/284, 27.5%) reported not having yet begun any activities. The types of staff involved in undertaking parkrun practice activities comprised: GPs (n = 266/306, 86.9%), practice nurses (n = 163, 53.3%), receptionists (n = 158, 51.6%), practice managers (n = 121, 39.5%), administrators (n = 121, 39.5%), healthcare assistants (n = 86, 28.1%), and physician’s assistants (n = 3, 1.0%). Others (n = 28, 9.2%) included pharmacists and link workers (data not shown).
As shown in Table 2, practices were undertaking, or planning to undertake, a broad range of activities recommended in the Toolkit.11 Activities most frequently undertaken were: ‘encourage patients and carers to take part in parkrun’ (n = 228/287, 79.4%), ‘encourage staff to register for parkrun and give it a go’ (n = 224/291, 77.0%), and ‘display parkrun flyers/posters in waiting room’ (n = 216/292, 74.0%). Activities practices frequently described as planned were ‘include a parkrun page on the practice website, or a link to the parkrun website’ (n = 155/282, 55.0%), and ‘undertake a volunteer takeover at a parkrun event’ (that is, practice staff doing all of the parkrun volunteer roles on a particular day) (n = 143/273, 52.4%).
Table 2. Activities adopted by parkrun practices
When signposting patients to parkrun, the majority of practices suggested the patient attend with a friend or family member (n = 212/306, 69.3%), and one-quarter (n = 78, 25.5%) suggested attending with practice staff. Jogging/running (n = 257, 84.0%) or walking (n = 252, 82.4%) parkrun were most commonly suggested ways of participating, with two-thirds (n = 200, 65.4%) of practices suggesting volunteering at a parkrun event (data not shown).
From the interviews, it was evident that signposting to parkrun occurred in the context of becoming more physically active as a walker or runner, with awareness of the benefits of volunteering. There was acknowledgement of the inclusivity of parkrun being an important factor in determining whether someone might benefit from attending:
‘And if anybody comes in that is, you know, sad, lonely, wants to do some exercise, wants to do something that’s a bit inclusive, doesn’t have anybody to go with, doesn’t know where to go, I quite often will tell them to come down and join and get involved because it is so inclusive.’
(parkrun practice 2, GP)
Most (n = 165/220, 75.0%) practices reported that staff members had taken up parkrun since becoming a parkrun practice (data not shown). While this was less commonly reflected in the interviews, there was evidence that some practices had really embraced staff involvement; be it by taking part in the event together and inviting patients, doing a volunteer takeover, or encouraging staff to build up to parkrun after following programmes such as ‘Couch to 5k’.20 Staff participation was seen to be good for team morale and taking part as a practice could encourage subsequent participation, either as a volunteer or as a runner or walker:
‘We had a parkrun practice day out in [city] and we advertised it. We had flyers printed, we told people about it. And we had 20 of our staff members there […] It was a really nice day out, really good for team morale, really good for getting them out, getting them healthy and it happened to be a nice day in [city] as well. And we got one of our patients there.’
(parkrun practice 2, GP)
Even where the staff members had not become active in parkrun, it had sometimes opened opportunities for dialogue about becoming a more physically active workplace, with staff participating in activities that they felt comfortable doing.
For example, one practice had introduced tai chi sessions following such a discussion. However, there was scepticism evident in some interviews about the initiative having an impact on practice staff levels of physical activity:
‘I suspect that those [practice staff] who exercise might go along occasionally […] I suspect that those who don’t still won’t.’
(parkrun practice 5, GP)
Challenges in implementing parkrun practice activities
Lack of time
Many (n = 125/281, 44.5%) practices reported experiencing challenges in implementing activities (data not shown). Interview data expanded on these and key themes were lack of time, staff engagement, uncertainty about initiative take up, and promotional materials. Lack of time, especially for GPs, was the most commonly reported challenge: lack of time during consultations, time needed to discuss the initiative with colleagues, and the perception of having to invest personal time delivering the initiative:
‘I think this is a good initiative, but GPs are busy […] putting things up regularly on the website or going to the parkruns ourselves, go regularly and it’s a really good initiative, but as everyone is aware, general practice is absolutely stretched at the moment.’
(parkrun practice 5, GP)
‘In terms of clinicians, probably time is the, the challenge I have. You know, we have a 10 minute appointment or a 15 minutes appointment — how am I supposed to get this in as well?’
(parkrun practice 4, practice manager)
The survey responder was commonly an existing parkrunner and(or) physically active. Getting other members of staff to support the initiative was a challenge for some practices that sometimes hampered progress:
‘I did expect that in my practice, in the staff meeting when we did discuss it, that everybody would have been on-board. I did expect people to want to come along […] but it just never happened, apart from maybe a couple of people who started running. And then it didn’t really continue.’
(parkrun practice 9, GP trainee)
Lack of motivation
Lack of interest and enthusiasm by practice staff took several forms, namely; not feeling there was enough time to be involved, not being physically active or parkrunners themselves and therefore not motivated to promote it, or misunderstandings about what would be expected of them from parkrun and the RCGP:
‘I think the challenge has been people [practice staff] remembering to think about it [signposting]. It’s easy for me, because it’s so much part of my life […] but for other colleagues who don’t do that … some of my perhaps more sedentary colleagues, because they don’t understand it so well.’
(parkrun practice 3, GP)
‘The partners’ worry is that they [parkrun/RCGP] are going to be asking us to do stuff and we just don’t have the capacity for any more work […] I don’t know what the College [RCGP] is expecting, whether they are thinking that GPs will just do this in their spare time.’
(parkrun practice 5, GP)
Some practices cited a need for promotional materials, including provision of resources that could be tailored locally. Some practices requested that customisable parkrun practice t-shirts be produced and available for purchase so that patients would recognise practice staff at the parkrun event. Practical issues relating to the printing of resources (such as posters and flyers), specifically the materials being too colour heavy and costly to print out in large quantities, were described. Some practices had developed their own solutions; for example, one had created a small ‘ticket’ containing parkrun information that could be given to patients.
Non-registered practices
Of the four non-registered practices who participated in interviews, three were aware of the initiative. They perceived it as being potentially beneficial and there was interest in registering in the future. They recognised that participation in parkrun could lead to social benefits, wellbeing, prevention of future health problems, improved patient health, and reduced strain on GP services.
The predominant reason given for not having registered as a practice was lack of time, both in terms of the limited duration of consultations and the perception of having to attend parkrun itself:
‘I’d said [to practice staff] “would anyone be interested?” [in parkrun practice] but a lot of our doctors and nurses all don’t live in [town], so I think people […] were thinking […] they’ve got a lot of commitments and, as have I. You know, we’re happy to do it, but it’s just, I think people just don’t want to be committed to nine o’clock every Saturday morning.’
(non-registered practice 4, practice nurse)
One practice, with a small list size and elderly patient population, felt that they would not get much uptake from their patients and it would be difficult to raise enough awareness of the initiative:
‘I think its [limiting factor] just not raising awareness enough […] being small […] we tend to get the same people in all the time, if you know what I mean.’
(non-registered practice 3, practice manager)
DISCUSSION
Summary
This study provides evidence about how general practice in the UK is engaging with the parkrun practice initiative. parkrun practices viewed the initiative positively, acknowledging its potential for encouraging patients and staff to become more active. Many were proud of their association with parkrun and display flyers and posters in their waiting rooms, and encourage patients and staff to take part in parkruns. Many had plans to create a parkrun page on their practice website or undertake a volunteer takeover. The main challenges were lack of time, and in some practices lack of wider engagement of staff. In practices where staff were engaged, staff had taken part in parkrun together, including volunteering as a team; this was felt to encourage subsequent participation in parkrun and improve staff morale. Getting practice staff enthused in the first instance was recognised as a key factor in the success of the initiative.
Strengths and limitations
This study merged quantitative and qualitative data to provide a comprehensive evaluation. Although the response rate of 39.2% was relatively high for surveys within general practice,21 practices that took part may be those that are more committed to the initiative and therefore may not be representative of all registered practices. In addition, data collection took place within the first year of national implementation of this initiative, and while this is useful in providing early insights about how practices experience the initiative, it is likely that their perceptions will change as the initiative becomes more established. Future research is planned to investigate if and how perceptions and levels of engagement have changed in subsequent years.
Comparison with existing literature
Husk and colleagues22 recently described the challenges involved in developing an evidence base in social prescribing. Many of those described here for the parkrun practice initiative are similar to those reported in other types of social prescribing; particularly, engagement from other staff members.23,24 Unlike other social prescribing activities, however, the parkrun practice initiative was commonly, but not always, initiated by a practice staff member who was already involved in the activity themselves. As such, this makes it an activity that patients may take part in with their GP or other practice staff members, giving practice staff the opportunity to become role models.25
Social prescribing services require a strong voluntary and community sector, which can limit their availability.26 Most significantly, this study did not identify any significant challenges of practices engaging with local parkrun events, reflecting that parkrun events are widely available, accessible, and welcoming. Wide ranging health benefits have been shown in people who volunteer, as well as those who run or walk the 5 km.13
The main challenge of lack of time coincides with previous studies on advising patients about physical activity in primary care, where lack of time is particularly highlighted by GPs.27
The online survey and interviews showed a breadth of ways in which practices are implementing the initiative, and adapting this to their local style of working and priorities. Indeed, the parkrun practice Toolkit11 and Tobin28 encourage practices and local parkruns to be creative and adopt whatever approach works best for them. This non-prescriptive approach is certainly borne out in the findings of this research.
Implications for research and practice
Lack of time is one of the biggest challenges that practices face, with some practices expressing concern about additional demands on their time occurring through becoming a parkrun practice. It may be that RCGP and parkrun could develop resources that specifically address these challenges and suggest solutions, for example, how to signpost in a time efficient way and methods to engage staff. A lack of enthusiasm from practice staff may stem from a misunderstanding of what is involved, and clarifying the logistics and aim of parkrun to the practice team when joining the initiative may help address this. The findings of this study indicate that GPs are usually the leaders of the initiative at practice level, but that other staff members are also involved. Whereas healthcare professionals are well placed to signpost during a consultation, non-clinical staff can also be involved with attending parkrun with patients, promotion within the practice, and encouraging patients to participate. Collaborating with other GPs and staff in the practice or elsewhere can increase motivation and lead to more sustained results.29
The practices which are innovative and able to drive the initiative most successfully appear to be those where the wider practice team is involved. The challenge for parkrun and RCGP in the future expansion of this initiative is determining ways to engage with practices who are not already familiar with parkrun and its potential benefits. With the increased adoption of ‘social prescribers’ or ‘link workers’ to GP practices, their role in adopting and delivering the initiative may become important.
Future research should explore patients’ experiences of being signposted to parkrun by their practices and how this impacts on subsequent uptake and health outcomes. In addition, the perspective of parkrun event teams needs to be investigated to further explore ways of improving and expanding the initiative.
