This mixed methods study provides important new insights into the factors influencing patient attendance at lifestyle intervention programs for the prevention of chronic disease. Over a third of individuals referred to the programs in this study did not attend any sessions, and a further small proportion (4.1%) attended less than half. However, the majority of those who attended initially continued to do so. Individuals who were older, did not work and had higher levels of psychological distress were significantly more likely to attend, while work commitments or problems with accessing the program were seen as important obstacles. GP/practice endorsement of the program and encouragement from group facilitators promoted attendance, along with flexibility arrangements including providing sessions outside of working hours.
Thus the LMP was most strongly taken up by non-working individuals, most of whom were retired. Conflicts with work schedules has been recognised as a reasons for not attending health education programs
[39–43], although one study of patients with existing CVD reported greater participation by employed individuals
. There was also a suggestion from Intervention Officers that older individuals were more motivated to attend because they saw themselves as more susceptible to ill health, although age was not an independent predictor of attendance in the quantitative analysis. The challenge is to develop lifestyle programs that better engage individuals who are working. This could include lifestyle programs run through workplaces, internet based programs or telephone counselling. While such approaches have been shown to be effective in promoting lifestyle change
[45–50], again little is known about the reach of such programs and levels of participation.
Interestingly, those with higher levels of psychological distress were more likely to attend the lifestyle program. The social interaction provided by the group may have been a motivator to attend for those with higher levels of distress. Previous studies examining associations between psychological distress and use of health service have shown conflicting results, with some studies reported increased use of primary health care services for those with high psychological distress
[51, 52], while others have shown that psychological distress is associated with higher rates of drop out from cardiac rehabilitation programs
. Further research is warranted to explore the associations between psychological distress and attendance and use of preventive health services.
Having GPs and practice nurses endorse the program was seen to encourage participation, and practices that were linked with allied health practitioners and had written preventive care protocols were more successful in promoting attendance. This suggests that practices should be briefed about their role in promoting the program, and given timely feedback following the program to encourage further referral and uptake
, and that this may be assisted by encouraging strong relationships with allied health professionals and a more formalized approach to risk factor management within the practice. Involving group facilitators in enrolling participants may also improve attendance rates.
A number of access problems were identified. This is in line with previous research on poor attendance at health education programs
[18, 41, 42, 55]. Access could be improved by running programs in community venues with good public transport links and parking facilities, and through the use of outreach programs such as telephone/internet based programs for rural and remote areas. However, these latter options do not provide the social interaction found in a group program, and may consequently be less appealing. The study also highlights the importance of flexibility in program delivery including providing sessions in the evening and weekends and offering individual intervention and telephone follow up to boost participation rates.
Interestingly, there was no association between the participants’ health risk profile or readiness to change at baseline and attendance rates at the program. This may be because GPs were more likely to refer high risk individuals who were ready to make lifestyle changes. A separate analysis has revealed that, consistent with the study protocol, individuals with elevated BMI, physical inactivity and who were in contemplation/preparation/action stages of change for physical activity were more likely to be referred
. The lack of association between participant’s stage of change and program participation may also reflect the fact that stages of change are not static categories and that individuals can shift between stages over a relatively short period of time. There was also no relationship with consumer’s health seeking behaviour as measured by the screening tool developed by Maibach et al.
. All our participants were categorised as ‘passive’ with regard to their health orientation, and their participation was not related to their degree of independence in health decision making. This is in contrast to the Intervention Officers’ perceptions that GPs’ endorsement encouraged attendance. It may be that the tool to measure consumer health information preferences is not valid in Australia, or that other factors were more important in determining participation.
Our findings suggest the value of the social interaction and support provided in a group program for encouraging attendance. Evidence also suggests that a group approach may be more effective in promoting weight loss than individual intervention
. The findings highlight the importance of group leaders having good facilitation skills in order to create a comfortable and inclusive group atmosphere. The non–expert role of the Intervention Officers in this study was reported to facilitate engagement and rapport building with participants, suggesting the potential value in lay or non professionally led programs.
This study focused on factors influencing participation in LMP amongst those eligible to attend (ie those completing a health check and referred by their GP). It is important to acknowledge however, that only around 30% of those initially invited to participate in the study agreed to do so. Factors influencing enrolment in diabetes and CVD prevention programs are an important and related issue. Many efficacy and replication trials have not provided any information on enrolment rates amongst eligible participants
[12, 58–65]. In other trials the proportion of eligible participants who agreed to enroll has varied widely from a third to 100 percent
[8, 9, 18, 66–71]. Little is known about factors influencing enrolment in these programs. As with this study, it is often difficult to examine predictors of enrolment as ethics requirements prevent information being collected on individuals invited who decline to participate. In order to improve the reach of these programs, factors influencing both enrolment and program completion are important areas for ongoing research.
This study had a number of limitations. We did not conduct follow up interviews with participants who were low attenders of the LMP, although we did ask for reasons for non attendance in the 12 month participant survey. Qualitative interviews with participants who are invited but do not attend lifestyle programs could elicit further insights into factors influencing participant engagement and the way programs could be modified to improve future attendance.