An Investigation into GP's Promotion, Prescription and Referral of Physical Activity for Obesity

Title: Ethics Supplementary Information

Table of Contents

Section A: Detailed study rationale………………………………………………..3

Section B: study aims and hypothesis……………………………………….…….5

Section C: Detailed Testing Protocol…………………………………….….…….6

Participant Information Sheet……………………………………….…….………9

Participant Informed Consent …………….………………………………….…..10

Participant Recruitment Email……………………………………………..….….13

Bibliography …………………………………………………………….….……14

Section A: Detailed study rationale

General practitioners (GP’s) are crucial influencers of patient behaviour and important initiators in the prevention of non-communicable disease. Therefore, they can inspire large amounts of the general population (NERF,2016, p.10). Patients identify GP’s as credible sources of information (Haddad et al, 2000). This is evident when it comes to the adoption of healthy lifestyle decisions as patients report their GP as their primary source of information in regards to healthier behaviours and PA (Oberg and Frank, 2009., Lobelo and De Quvodo,2016). A major predictor of whether GPs promote healthy lifestyle behaviours to their patients is whether they engage in a healthy lifestyle themselves (Oberg and Frank, 2009) This can be attributed to general practitioners’ reluctance and/or difficulty in recommending strategies that they themselves do not adhere to (McKenna, Naylor and McDowell, 1998). This is evident in a study by Keohane et al (2018) where it was discovered that 50% of Irish GP’s currently fail to reach the recommended physical activity levels (30 min per day, preferably 7 days a week). According to Fraser et al (2013) Patient’s perceptions of the health advice received during consultations are heavily influenced by the perceived health status of the GP. However, evidence suggests that promotion of PA in primary care can significantly increase PA levels in physically inactive populations. (Orrow et al., 2012., NICE,2006). However, In Ireland, there is a lack of information on the current status of physical activity promotion for obesity specifically in relation to General Practitioners.

Get Help With Your Nursing Essay

If you need assistance with writing your nursing essay, our professional nursing essay writing service is here to help!

Nursing Essay Writing Service

There is mixed evidence on whether referral to community-based exercise programmes improves the rate of physical activity/Exercise participation (Orrow et al 2012., Murphy et al, 2012., Campbell et al, 2015., Williams et al,2007). However, In regards to obesity, community-based exercise programmes have been proven to produce reductions in weight (Clark et al, 2010). As stated above GP’s are vital influencers of patient behaviour and their referral to community-based programmes would be a crucial step to decrease the rates of obesity in Ireland (NERF,2016, p.10).

Obesity can be defined as excessive or abnormal fat accumulation that presents a risk to life, whereby a person with a BMI (Body mass index) of ≥30 is considered obese (WHO, 2018). Obesity is a major risk factor for depression (Roberts et al., 2003; Kasen et al., 2007; Luppino et al., 2010), and chronic diseases, including cardiovascular diseases (Poirier et al., 2006), diabetes (Algoblan, Alalfi and Khan, 2014) and cancer (Bhaskaran et al., 2014).  As a result, obesity is a significant contributing factor to mortality and morbidity (Pi-Sunyer, 2002., Lenz, Richter and Mühlhauser, 2009., Abdelaal, le Roux and Docherty, 2017). The increased rates of obesity associated with the last 100 years can be attributed to shifts in nutritional norms and patterns of sedentary behaviour (Popkin, Adair and Ng, 2012., Owen et al., 2010). According to Wiklund, (2016) PA has the potential to be a solution for this ever-growing crisis.

Physical inactivity accounts for approximately 5.3 million (9%) deaths globally per year and it is estimated that if physical inactivity was reduced 25%, more than 1.3 million deaths could be prevented annually (Lee et al., 2012). Physical activity can be defined as any bodily movement produced by skeletal muscles that require energy use (Alricsson, 2013). Many studies have shown a positive correlation between increased levels of physical activity and a reduction in obesity and related symptoms (Swift et al, 2014; Wiklund, 2016; Strasser, 2012). Along with a reduction of obesity related comorbidities physical activity also has been linked to a lessoning of depression symptoms and an increase in quality of life (Gill et al., 2013). The American College of Sports Medicine in a 2009 recommendation’ outlined strategies for weight loss and the prevention of weight gains. In which they stated that:

“Moderate-intensity PA of 150 to 250 min-wk. with an energy equivalent of 1200 to 2000 kcal-wk. seems sufficient to prevent weight gain greater than 3% in most adults” (Donnelly et al, 2009).

and for people suffering from obesity:

“PA that approximates 250 to 300 min-wk. (approximately 2000 kcal-wk.) of moderate intensity PA” (Donnelly et al, 2009).

This study hopes to identify if GP’s prescription of physical activity meets the guidelines set out be the ACSM.

With the current Irish health care system under significant pressure, physical activity would be an uncomplicated intervention with a strong evidence base that is easily accessible, free and non-discriminatory. In Ireland, the recommended levels of physical activity are 30 minutes of moderate activity 5 days per week (or 150mins/wk.) (Department of Health,2015, p.8). The Healthy Ireland Survey (2015) outlined that 32% of the Irish population are considered to be highly active with men being more (40%) active than women (24%), Thereby resulting in a physical inactivity rate of 68%. This high level of inactivity highlights the question of physical activity promotion and prescription within the Irish context and whether it meets the guidelines set by the ACSM.

section b: study aims and hypothesis

Study Aims:

The aim of this study is to examine what GP’s know about exercise promotion, prescription and referral of physical activity in relation to obesity in Ireland

Research Questions

Research questions are more applicable to this study. These include:

•Is the current level of physical activity promotion provided by GP’s’ sufficient for the prevention of obesity?

•Upon examination, do Irish GP’s prescribe physical activity in accordance with the most recent physical activity levels recommended by the American College of Sports Medicine? (2009 recommendations)

•Is referral of physical activity utilised as a tool to tackle obesity? If so, how?

•Do barriers exist when promoting, prescribing or referring physical activity to patients? If so what are they?

Section C: Detailed Testing Protocol

Testing Protocol Overview

Study design:

This study will be a cross-sectional analysis carried out via questionnaire. It will cover the topics of GP’s promotion, prescription and referral of physical activity for obesity in Ireland. Within will be a series of statements for which participants will agree or disagree along with some open-ended question based around promotion and prescription of PA.

Participants and setting:

The participants for this study will be general practitioners of all ages and gender who work and are located in Ireland with inclusion and exclusion criteria as follows:

Inclusion of participants:

Criteria for inclusion:

• General practitioners located in Ireland will be allowed to participate

Exclusion of participants:

Criteria for exclusion:

• General practitioners located outside of Ireland
• General practitioners who no longer work
• General practitioners in training

Recruitment:

Recruitment will be different for the electronic-based and paper-based questionnaire. The ICGP (Irish College of General Practitioners) is a national organisation that has access to many GP’s and general practices across the country. In order to recruit for the paper-based questionnaire, I will get in contact and request to attend some of their annual meetings. The ICGP also has contact details of many GP’s and general practitioners across the country. I will request that my questionnaire be distributed. Along with this, I will contact general practices in my local region and formally request their participation.

Questionnaire development:

The questionnaire will be both an electronically based (Created on survey monkey) and paper-based which will maximise the population size. Principles for the creation of the online survey will be inspired from Dillan et al, (1998), Edwards et al, (2009) and Kelly (2003) in regards to maximising response rates. The questionnaire will consist of multiple-choice, open-ended and statement-based questions and will take influence from questionnaires acquired from (Cantwell et al, 2017., O’Hanlon and Kennedy, 2014., Chatterjee et al., 2017,. Wheeler et al., 2017). The official questionnaire will take considerable time to create and will not be available for the ethics form. However, below are examples of questionnaire formats and style of questions that will be adapted to fit the purpose of this study:

• How familiar or unfamiliar are you with the 2015 physical activity recommendations provided by the department of health.

□Very Familiar

□Familiar

□Unfamiliar

□Very unfamiliar

• How do you promote physical activity to obese patients (Tick any that apply)?

□Verbal advice

□Pamphlets/ information sheets

□Refer onto physiotherapist or specialised exercise professionals

□Not applicable (I do not give advice)

□Other (Give description below)

• When prescribing physical activity to obese patients what are your general recommendations in terms of the following:

-Frequency (Number of sessions per week)

-Intensity (Light, moderate or vigorous)        

-Time (Minutes per session)                            

-Type (Aerobic or resistance training)            

-Not applicable (I do not give advice based off these headings). If so please state what recommendations you provide

• Discussing physical activity with obese patients is part of my role as a general practitioner.

□ Strongly agree

□ Agree

□ Neither agree nor disagree

□ Disagree

□ Strongly disagree

• Are there any perceived barriers that limit GP’s from discussing physical activity with their patients (Tick whichever apply)?

□Insufficient time

□Insufficient resources

□Lack of Knowledge of physical activity

□Patients are unlikely to adhere to advice

□Not my professional role

Statistical analysis:

When the questionnaires are received they will be quantitatively analysed using descriptive statistical methods as described by Elo and Kyngäs (2008). This will be analysed using the Crosstabs procedure within the Statistical Package for the Social Sciences (SPSS).

Purpose of study: This study aims to provide information on GP’s (General Practitioners)’ promotion, prescription and referral of physical activity for obesity in Ireland. This study stems from a lack of knowledge in regards to GP’s strategies for combating obesity using physical activity. Therefore, the purpose of this study is to Investigate the degree to which GP’s (General Practitioners) promote, prescribe and refer physical activity to obese patients in Ireland. This study hopes to provide information on the current level of physical activity awareness amongst GP’s.

Do I have to participate in the study? No, Participation is voluntary. You are entitled to withdraw from the study at any time. There is no obligation to remain involved if you no longer wish to.

What will I have to Do during the study? You will be required to fill out either an online or paper-based questionnaire regarding physical activity promotion and prescription for obese patients. The questionnaire will consist of multi-choice, open-ended and statement-based questions.

Are there any possible risks associated with taking part in the study? There are no perceived or foreseeable risks to partaking in this study.

Will the study be confidential? All participant details will remain confidential and a strict policy of anonymity will be adhered to throughout and thereafter the studies duration. Anonymity will be maintained by allocation a random ID number to each participant. All data collected will follow EU General Data Protection Regulations and will be stored electronically via a flash drive in a secure location with only my supervisor and I having access. The study findings will be presented for the researchers’ thesis but your identity will not be revealed. After a five-year period, all data will be destroyed following AIT policy.

Benefits

This study aims to benefit GP’s’ by furthering their knowledge of physical activity promotion, prescription, and referral in regards to obesity.

Purpose of study: This study aims to provide information on GP’s (General Practitioners)’ promotion, prescription and referral of physical activity for obesity in Ireland. This study stems from a lack of knowledge in regards to GP’s strategies for combating obesity using physical activity. The purpose of this study is to Investigate the degree to which GP’s (General Practitioners) promote, prescribe and refer physical activity to obese patients in Ireland. This study hopes to provide information on the current level of physical activity awareness amongst GP’s.

Do I have to participate in the study? No, Participation is voluntary. You are entitled to withdraw from the study at any time. There is no obligation to remain involved if you no longer wish to.

What will I have to Do during the study? You will be required to fill out either an online or paper-based questionnaire regarding physical activity promotion and prescription for obese patients. The questionnaire will consist of multi-choice, open-ended and statement-based questions.

Are there any possible risks associated with taking part in the study? There are no perceived or foreseeable risks to partaking in this study.

Will the study be confidential? All participant details will remain confidential and a strict policy of anonymity will be adhered to throughout and thereafter the studies duration. Anonymity will be maintained by allocation a random ID number to each participant. All data collected will follow EU General Data Protection Regulations and will be stored electronically via a flash drive in a secure location with only my supervisor and I having access. The study findings will be presented for the researchers’ thesis but your identity will not be revealed. After a five-year period, all data will be destroyed following AIT policy.

Benefits: This study aims to benefit GP’s’ by furthering their knowledge of physical activity promotion, prescription, and referral in regards to obesity.

Please fill out the following (Tick Yes or No for the following questions)

I have read the participant information sheet

Yes                        No

I fully understand the information provided

Yes       No

I have been given time to inquire and discuss the study

Yes No

I have revived answers that satisfy all my questions

Yes No

Signature:

I have read and can understand all the information provided in this form.  My queries and concerns have been addressed by the researchers, and I have been given a copy of the participant information sheet. Therefore, I consent to take part in this research project.

Participants Signature: _______________                        Date__________________

Name: _____________________________

Witness____________________________                         Date___________________

Dear Dr.__________

I’m a 4^th Sports Science student studying in Athlone Institute of technology. I am contacting you to extend an invitation to participate in a new and exciting study into GP’ promotion, prescription and referral of physical activity for obesity in Ireland.

The purpose of this study is to Investigate the degree to which GP’s (General Practitioners) promote, prescribe and refer physical activity to obese patients in Ireland. There is an absence of evidence in Ireland detailing the level of knowledge, prescription, and referral process in regards to physical activity for the obese population. This study hopes to provide information on the current level of physical activity awareness amongst GP’s.

This study will involve the following:

1. Participant informed consent form- Which will be signed electronically and sent back to this email along with the completed questionnaire.
2. Completing a questionnaire with questions on promotion, prescription and referral of physical activity for obesity in Ireland. The questionnaire will consist of open-ended, statement-based and Multiple-choice style questions.

If you would like to participate please fill out the informed consent and the questionnaire which are linked to this email. The informed consent must be signed by electronic signature and resent along with the completed questionnaire to this email. If you have any questions please feel free to contact me at:

I would greatly appreciate your participation in this study.

Kindest Regards,

Bibliography

• Abdelaal, M., le Roux, C. and Docherty, N. (2017). Morbidity and mortality associated with obesity. Annals of Translational Medicine, 5(7), pp.161-161. Available: doi: 10.21037/atm.2017.03.107
• Alricsson, M. (2013). Physical Activity Why and How? Journal of Biosafety & Health Education, 01(04). Available: doi:10.4172/2332-0893.1000e111
  Algoblan, A., Alalfi, M. and Khan, M. (2014). Mechanism linking diabetes mellitus and obesity. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, p.587.available: doi: 10.2147/DMSO.S67400
• Bhaskaran, K., Douglas, I., Forbes, H., dos-Santos-Silva, I., Leon, D. and Smeeth, L. (2014). Body-mass index and risk of 22 specific cancers: a population-based cohort study of 5·24 million UK adults. The Lancet, 384(9945), pp.755-765. available: doi: 10.1016/S0140-6736(14)60892-8
• Campbell, F., Holmes, M., Everson-Hock, E., Davis, S., Woods, H. B., Anokye, N., Kaltenthaler, E. (2015). A systematic review and economic evaluation of exercise referral schemes in primary care: A short report. Health Technology Assessment, 19(60), pp.1–110. available: doi: 10.3310/hta19600
• Cantwell M, Walsh D, Furlong B, et al. (2017) Healthcare professionals’ knowledge and practice of physical activity promotion in cancer care: Challenges and solutions. Eur J Cancer Care. available: doi :10.1111/ecc.12795
• Caspersen, C. J., Powell, K. E., & Christenson, G. M. (1985). Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Reports, 100(2), pp.126–131 Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1424733/pdf/pubhealthrep00100-0016.pdf
• Chatterjee, R., Chapman, T., Brannan, M. and Varney, J. (2017). GPs’ knowledge, use, and confidence in national physical activity and health guidelines and tools: a questionnaire-based survey of general practice in England. British Journal of General Practice, 67(663), pp. e668-e675. Available: doi: 10.3399/bjgp17X692513
• Clark, D., Chrysler, L.,Perkins,A., Keith,N.R., Willis,D.R., Abernathy,G.,Smith,Faye. (2010). Screening, Referral, and Participation in a Weight Management Program Implemented in Five CHCs. Journal of Heath care for the poor and underserved, 21(2): pp.617-628. Available: doi: 10.1353/hpu.0.0319.
• Department of Health (2015) National Physical Activity Plan for Ireland: Get Ireland Active. p8. Available at: https://health.gov.ie/wp-content/uploads/2016/01/Get-Ireland-Active-the-National-Physical-Activity-Plan.pdf. [Accessed 17 October 2018].
• Dillman, D. A., Tortora, R.D., & Bowker, D. (1998). Principles for constructing web surveys. Presented at the Joint Meetings of the American Statistical Association. Retrieved from: https://sesrc.wsu.edu/dillman/ papers/1998/principlesforconstructingwebsurveys.pdf [accessed 20 January 2017]

• Donnelly, J., Blair, S., Jakicic, J., Manore, M., Rankin, J. and Smith, B. (2009). Appropriate Physical Activity Intervention Strategies for Weight Loss and Prevention of Weight Regain for Adults. Medicine & Science in Sports & Exercise, 41(2), pp.459-471. available: doi: 10.1249/MSS.0b013e3181949333.

• Edwards, P. J., Roberts, I., Clarke, M. J., DiGuiseppi, C., Wentz, R., Kwan, I., Pratap, S. (2009). Methods to increase response to postal and electronic questionnaires. Cochrane Database of Systematic Reviews, 3. https://doi.org/10.1002/14651858.MR000008.pub4
• Elo, S. and Kyngäs, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), pp.107-115. Available: doi:10.1111/j.1365-2648.2007.04569.x.
• Fraser SE, Leveritt MD, Ball LE. (2013). Patients’ perceptions of their general practitioner’s health and weight influences their perceptions of nutrition and exercise advice received. Journal of Primary Health Care.5(4): pp.301-7. Retrieved from:  https://pdfs.semanticscholar.org/4866/b053fc44201c7966dbb6804010bdb5738766.pdf?_ga=2.196146411.651401993.1539175931-793785404.1539175931
• Gill, D., Hammond, C., Reifsteck, E., Jehu, C., Williams, R., Adams, M., Lange, E., Becofsky, K., Rodriguez, E. and Shang, Y. (2013). Physical Activity and Quality of Life. Journal of Preventive Medicine & Public Health, 46(Suppl 1), pp.S28-S34. Available: doi:  10.3961/jpmph.2013.46.S.S28
• Haddad, S., Potvin, L., Roberge, D., Pineault, R. and Remondin, M. (2000). Patient perception of quality following a visit to a doctor in a primary care unit. Family Practice, 17(1), pp.21-29. Available: https://doi.org/10.1093/fampra/17.1.21
• Healthy Ireland Survey (2015): Summary of Findings p. 25-31. Available at: https://health.gov.ie/wp-content/uploads/2016/10/Healthy-Ireland-Survey-2016-Summary-Findings.pdf. [17 October 2018].
• Kasen, S., Cohen, P., Chen, H. and Must, A. (2007). Obesity and psychopathology in women: a three-decade prospective study. International Journal of Obesity, 32(3), pp.558-566. Available: doi: 10.1038/sj.ijo.0803736
• Kelly, K. (2003). Good practice in the conduct and reporting of survey research. International Journal for Quality in Health Care, 15(3), p.261-266. Available: https://doi.org/10.1093/intqhc/mzg031
• Keohane, D M., Mulligan, N A., Daly, B (2018). Physical activity levels and perceived barriers to exercise participation in Irish General Practitioners and General Practice trainees. Irish Medical Journal. Available: http://imj.ie/physical-activity-levels-and-perceived-barriers-to-exercise-participation-in-irish-general-practitioners-and-general-practice-trainees/
• Lee, I., Shiroma, E., Lobelo, F., Puska, P., Blair, S. and Katzmarzyk, P. (2012). Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. The Lancet, 380(9838), pp.219-229. Available: doi: 10.1016/S0140-6736(12)61031-9.
• Lenz, M., Richter, T. and Mühlhauser, I. (2009). The Morbidity and Mortality Associated With Overweight and Obesity in Adulthood. Deutsches Aerzteblatt International. 106(40): pp.641–648. Available: doi: 10.3238/arztebl.2009.0641
• Lobelo, F., de Quevedo, I. G. (2016). The Evidence in Support of Physicians and Health Care Providers as Physical Activity Role Models. American Journal of Lifestyle Medicine, 10(1), pp.36–52. Available: doi: 10.1177/1559827613520120
• Luppino, F., de Wit, L., Bouvy, P., Stijnen, T., Cuijpers, P., Penninx, B. and Zitman, F. (2010). Overweight, Obesity, and Depression. Archives of General Psychiatry, 67(3), p.220 available: doi: 10.1001/archgenpsychiatry.2010.2.
• McKenna, J., Naylor, P. and McDowell, N. (1998). Barriers to physical activity promotion by general practitioners and practice nurses. British Journal of Sports Medicine, 32(3), pp.242-247. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1756103/pdf/v032p00242.pdf
• Morgan, O. (2005). Approaches to increase physical activity: reviewing the evidence for exercise-referral schemes. Journal of the Royal Institute of Public Heath, 119(5), pp.361-370. Available: doi: 10.1016/j.puhe.2004.06.008
• Murphy, S., Edwards, R., Williams, N., Raisanen, L., Moore, G., Linck, P., Hounsome, N., Din, N. and Moore, L. (2012). An evaluation of the effectiveness and cost effectiveness of the National Exercise Referral Scheme in Wales, UK: a randomised controlled trial of a public health policy initiative. Journal of Epidemiology and Community Health, 66(8), pp.745-753. Available: doi: 10.1136/jech-2011-200689
• NICE: National Institute of Health and Clinical Excellence (2006). A rapid review of the effectiveness of brief interventions in primary care to promote physical activity in adults. Retrieved from: https://www.nice.org.uk/guidance/ph2/documents/physical-activity-ph2-exercise-referral-review-decision2
• O’Hanlon, É. and Kennedy, N. (2014). Exercise in cancer care in Ireland: a survey of oncology nurses and physiotherapists. European Journal of Cancer Care, 23(5), pp.630-639. Available: https://doi.org/10.1111/ecc.12206
• Oberg, E. and Frank, E. (2009). Physicians’ health practices strongly influence patient health practices. The Journal of the Royal College of Physicians of Edinburgh, 39(4), pp.290-291. Available: doi:10.4997/JRCPE.2009.422
• Orrow, G., Kinmonth, A., Sanderson, S. and Sutton, S. (2012). Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ, 344(mar26 1), pp. e1389-e1389. Available: doi:10.1136/bmj.e1389.
• Owen, N., Healy, G., Matthews, C. and Dunstan, D. (2010). Too Much Sitting. Exercise and Sport Sciences Reviews, 38(3), pp.105-113. Available: doi:10.1097/JES.0b013e3181e373a2
• Pi-Sunyer, F. (2002). The Medical Risks of Obesity. Obesity Surgery, 121(6): pp. 21–33. Available: doi: 10.3810/pgm.2009.11.2074.
• Poirier, P., Giles, T., Bray, G., Hong, Y., Stern, J., Pi-Sunyer, F. and Eckel, R. (2006). Obesity and Cardiovascular Disease: Pathophysiology, Evaluation, and Effect of Weight Loss. Circulation, 113(6), pp.898-918. Available: doi: 10.1161/CIRCULATIONAHA.106.171016
• Popkin, B., Adair, L. and Ng, S. (2012). Global nutrition transition and the pandemic of obesity in developing countries. Nutrition Reviews, 70(1), pp.3-21. Available: doi:10.1111/j.1753-4887.2011.00456.x
• Roberts, R. E., Deleger, S., Strawbridge, W.J., Kaplan, G.A. (2003) Prospective association between obesity and depression: evidence from the Alameda County Study. International Journal of Obesity, 27(4), pp.514-521. Available: doi: 10.1038/sj.ijo.0802204
• Strasser, B. (2012). Physical activity in obesity and metabolic syndrome. Annals of the New York Academy of Sciences, 1281(1), pp.141-159. Available: doi:  10.1111/j.1749-6632.2012.06785.x
• Swift, D. L., Johannsen, N. M., Lavie, C. J., Earnest, C. P., & Church, T. S. (2014). The Role of Exercise and Physical Activity in Weight Loss and Maintenance. Progress in Cardiovascular Diseases, 56(4), pp.441–447. Available: doi:10.1016/j.pcad.2013.09.012
• Wheeler, P., Mitchell, R., Ghaly, M. and Buxton, K. (2017). Primary care knowledge and beliefs about physical activity and health: a survey of primary healthcare team members. BJGP Open, 1(2). Available: doi: https://doi.org/10.3399/bjgpopen17X100809
• Wiklund, P. (2016). The role of physical activity and exercise in obesity and weight management: Time for critical appraisal. Journal of Sport and Health Science, 5(2), pp.151-154. Available: https://doi.org/10.1016/j.jshs.2016.04.001
• Williams, N.H., Hendry, M., France, B., Lewis, R., Wilkinson, C. (2007). Effectiveness of exercise-referral schemes to promote physical activity in adults: systematic review. British Journal of General Practice, 57(545): pp.979–986. Available: doi: 10.3399/096016407782604866
• Who.int. (2018). WHO | Obesity. [online] Available at: http://www.who.int/topics/obesity/en/ [Accessed 2 Oct. 2018]. In text (Who.int, 2018)
• Woodcock, J., Franco, O. H., Orsini, N., & Roberts, I. (2010). Non-vigorous physical activity and all-cause mortality: systematic review and meta-analysis of cohort studies. International Journal of Epidemiology, 40(1), pp.121–138. Available: doi: 10.1093/ije/dyq104
• Woods C., McCaffrey N., Furlong B., Fitzsimons-D’Arcy L., Murphy M., Harrison M.,Glynn L., O’Riordan J., O’Neill B., Jennings S. and Peppard C. (2016) The National Exercise Referral Framework. Health and Wellbeing Division, Health Services Executive. Dublin. Ireland. Retrieved from: https://arrow.dit.ie/cgi/viewcontent.cgi?article=1007&context=engschcivrep