Review of Primary Care-Based Physical Activity Intervention Studies

,

Original Research

Review of Primary Care-Based Physical Activity Intervention Studies

J Fam Pract. 2000 February;49(2):158-168

By

Elizabeth G. Eakin, PhD

Effectiveness and Implications for Practice and Future Research

References

1. US Department of Health and Human Services. Physical activity and health: a report of the Surgeon General Executive Summary. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, The President’s Council on Physical Fitness and Sports. Atlanta, Ga: US Government Printing Office; 1996.

2. National Institutes of Health. Physical activity and cardiovascular health. JAMA 1996;76:241-6.

3. Harris SS, Caspersen CJ, DeFriese GH, et al. Physical activity counseling for healthy adults as a primary preventive intervention in the clinical setting: report for the US Preventive Services Task Force. JAMA 1989;261:3590-8.

4. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-7.

5. Paffenbarger RS, Hyde RT, Wing AL, Hsieh C-C. Physical activity, all-cause mortality, and longevity of college alumni. N Eng J Med 1986;314:605-13.

6. US Department of Health and Human Services. Health promotion and older adults. Prev Rep 1989;1-5.

7. Clark NM, Becker MH, Janz NK, Lorig K, Rakowski W, Anderson L. Self-management of chronic disease by older adults. J Aging Health 1991;3:3-27.

8. Jones DA, Ainsworth BE, Croft JB, Macera CA, Lloyd EE, Yusuf HR. Moderate leisure-time physical activity: Who is meeting the public health recommendations? A national cross-sectional study. Arch Fam Med 1998;7:285-9.

9. US Department of Health and Human Services Office Public Health and Science. Healthy people 2010 objectives: draft for public comment. 1998.

10. Pinto BM, Goldstein MG, Marcus BH. Activity counseling by primary care physicians. Prev Med 1998;27:506-13.

11. US Department of Health and Human Services. Promoting health/preventing disease year 2000 health objectives for the nation. 1990.

12. US Preventive Services Task Force. Guide to clinical preventive services: an assessment of the effectiveness of 169 interventions. Baltimore, Md: Williams & Wilkins, 1989.

13. Damush TM, Stewart AL, Millls K, King AC, Ritter PL. Prevalence and correlates of physician recommendations to older adults to exercise. Ann Behav Med 1998;20:S194.-

14. Eakin EG, Glasgow RE. Recruitment of managed care Medicare patients for a physical activity study. Am J Health Promo 1997;12:98.-

15. Beaven DW, Scott RS. The organization of diabetes care. In: Alberti KGMM, Krall LP, eds. The diabetes annual 2. New York, NY: Elsevier; 1986;39-48.

16. Orlandi MA. Promoting health and preventing disease in health care settings: an analysis of barriers. Prev Med 1987;16:119-30.

17. Glasgow RE, McKay HG, Boles SM, Vogt TV. Interactive technology, behavioral science, and health care: progress, pitfalls, and promise. J Fam Pract 1999;48:464-70.

18. Simons-Morton DG, Calfas KJ, Oldenburg B, Burton NW. Effects of interventions in health care settings on physical activity or cardiorespiratory fitness. Am J Prev Med 1998;15:413-30.

19. Goldstein MG, Pinto BM, Marcus BH, et al. Physician-based physical activity counseling for middle-aged and older adults: a randomized trial. Ann Behav Med In press.

20. Eaton CB, Menard LM. A systematic review of physical activity promotion in primary care office settings. Br J Sports Med 1998;32:11-6.

21. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health In press.

22. Flay BR. Efficacy and effectiveness trials (and other phases of research) in the development of health promotion programs. Prev Med 1986;15:451-74.

23. Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs, NJ: Prentice Hall; 1986.

24. Bandura A. Self-efficacy: the exercise of control. New York, NY: W.H. Freeman, 1997.

25. Strecher VJ, Seijts GH, Kok GJ, et al. Goal setting as a strategy for health behavior change. Health Educ Q 1995;22:190-200.

26. Glasgow RE, Eakin EG. Medical office-based interventions. In: Snoek FJ, Skinner CS, eds. Psychological aspects of diabetes care. In press.

27. Wagner EH, Austin B, Von Korff M. Improving outcomes in chronic illness. Manag Care Q 1996;4:12-25.

28. Prochaska JO, Velicer WF, Rossi JS, et al. Stages of change and decisional balance for 12 problem behaviors. Health Psychol 1994;13:39-46.

29. Marcus BH, Rakowski W, Rossi JS. Assessing motivational readiness and decision-making for exercise. Health Psychol 1992;11:2457-61.

30. Marcus BH, Goldstein MG, Jette AM. Training physicians to conduct physical activity counseling. Prev Med 1997;26:382-8.

31. Graham-Clarke P, Oldenburg B. The effectiveness of a general-practice-based physical activity intervention on patient physical activity status. Behavior Change 1994;11:132-44.

32. Bull FC, Jamrozik K. Advice on exercise from a family physician can help sedentary patients to become active. Am J Prev Med 1998;15:85-94.

33. Reid LR, Morgan RW. Exercise prescription: a clinical trial. Am J Public Health 1979;69:591-5.

34. Gochman DS, Gochman DS, eds. Handbook of health behavior research II. New York, NY: Plenum Press; 1997.

35. Glasgow RE, Eakin EG. Issues in diabetes self-management. In: Shumaker SA, Schron EB, Ockene JK, McBee WL, eds. The handbook of health behavior change. 2nd ed. New York, NY: Springer Publishing Company, 1998;435-61.

36. Glasgow RE, Eakin EG, Toobert DJ. How generalizable are the results of diabetes self-management research? The impact of participation and attrition. Diabetes Educ 1996;22:573-85.

37. Glasgow RE, McCaul KD, Fisher KJ. Participation in worksite health promotion: a critique of the literature and recommendations for future practice. Health Educ Q 1993;20:391-408.

38. Sorensen G, Emmons KM, Hunt MK, Johnston D. Implications of the results of the community intervention trials. Annu Rev Public Health 1998;19:379-416.

39. Orleans CT. Treating nicotine dependence in medical settings: a stepped-care model. In: Orleans CT, Slade J, eds. Nicotine addiction: principles and management. New York, NY: Oxford University Press, 1993;145-62.

40. de Vries H, Brug J. Computer-tailored interventions motivating people to adopt health promoting behaviors: Introduction to a new approach. Patient Educ Couns 1999;36:99-105.

41. King AC, Sallis JF, Dunn AL, et al. Overview of the Activity Counseling Trial (ACT) intervention for promoting physical activity in primary health care settings. Med Sci Sports Exerc 1998;30:1086-96.

42. Stewart AL, Sepsis PG, King AC, McLelland BY, Roitz K, Ritter PL. Evaluation of CHAMPS, a physical activity promotion program for older adults. Ann Behav Med 1997;19:353-61.

43. Sallis JF, Owen N. Physical activity and behavioral medicine. Turner JR, ed. Thousand Oaks, Calif: Sage Publications; 1999.

44. Piette JD, McPhee SJ, Weinberger M, Mah CA, Kraemer FB. Can patients with diabetes use automated telephone disease management calls effectively? In press.

45. Piette JD, Mah CA. The feasibility of automated voice messaging as an adjunct to outpatient diabetes care. Diabetes Care 1997;20:15-21.

46. Hollis JF, Lichtenstein E, Vogt TM, Stevens VJ, Biglan A. Nurse-assisted counseling for smokers in primary care. Ann Intern Med 1993;118:521-5.

47. Glasgow RE, La Chance P, Toobert DJ, Brown J, Hampson SE, Riddle MC. Long-term effects and costs of brief behavioral dietary intervention for patients with diabetes delivered from the medical office. Patient Educ Couns 1997;32:175-84.

48. Elder JP, Wright BL. Longitudinal effects of preventive services on health behaviors among an elderly cohort. Am J Prev Med 1995;11:354-8.

49. Jette AM, Lachman M, Giorgetti MM, et al. Exercise—it’s never too late: the Strong-for-Life Program. AM J Public Health 1999;89:66-72.

50. King AC, Oka R, Pruitt L, Philips W. Developing optimal exercise regimens for seniors: a clinical trial. Ann Behav Med 1997;19:S056.-

51. Pereira MA, FitzGerald SJ, Gregg EW, et al. A collection of physical activity questionnaires for health-related research. Med Sci Sports Exer 1997;29:S1-205.

OBJECTIVE: To summarize the literature on primary care-based interventions for increasing physical activity and make recommendations for future research and for integrating successful strategies into practice.

SEARCH STRATEGIES: We searched MEDLINE (1980 to 1998), psychological abstracts, ERIC and HealthStar databases, the Web site for The Journal of Family Practice, bibliographies of selected studies, and previous reviews for relevant articles. The search was limited to the English language. Three experts in the field of physical activity were contacted for leads on unpublished trials.

SELECTION CRITERIA: Inclusion criteria were: randomized controlled trial or quasiexperimental study using a comparison group, intervention delivered or initiated in a primary care setting, and reported results on at least 1 measure of physical activity. Studies that focused solely on patients with cardiovascular disease were excluded.

MAIN RESULTS: Primary care-based physical activity counseling is moderately effective in the short term, although there is considerable variability across studies. Studies in which the interventions were tailored to participant characteristics and which offered written materials to patients produced stronger results. Unlike many types of health promotion, the reach of primary care-based physical activity interventions is high. Questions remain about the consistency of implementation and long-term maintenance of outcomes.

CONCLUSIONS: Despite the need for further research, enough is known to recommend integration of key strategies of physical activity counseling into routine practice. We recommend incorporating these strategies into primary care and prioritizing them for further research.

Clinical Question

What strategies are practical and effective to use in family practice settings to enhance levels of patient physical activity?

Regular physical activity is essential for disease prevention and health promotion.^1-4 Even moderate levels of physical activity are associated with a reduced incidence of a variety of chronic conditions.^1,3-7 National recommendations for physical activity from the American College of Sports Medicine and the Centers for Disease Control and Prevention state that all adults should accumulate 30 minutes a day of moderate intensity activity on 5 or more days per week. However, only 32% of US adults achieve that level.⁸

The National Health Promotion and Disease Prevention Objectives in Healthy People 2010^9-11 and the US Preventive Services Task Force¹² recommend that physicians and other health care providers counsel their patients to be physically active, yet the majority of physicians do not. Two recent studies of older adults^13,14 found that 48% and 36% reported having received advice regarding physical activity from their physicians. Barriers to such counseling include skepticism about its efficacy, competing demands, lack of time, lack of reimbursement, and the lack of standardized assessment and procedure protocols that would make counseling feasible to for busy office settings.^15-17

We reviewed the literature on primary care-based physical activity interventions and offer evidence-based recommendations for incorporating them into practice. Our review differs from previous reviews of physical activity interventions in health care settings^18-20 because we evaluate studies using the RE-AIM framework which was developed for evaluating the public health impact of health promotion activities. We also included a methodologic quality rating for each study and reported or calculated effect sizes and odds ratios where possible.

The RE-AIM Framework

The RE-AIM framework²¹ focuses attention on a real-world effectiveness perspective²² compatible with the realities of medical office treatment. There are 5 dimensions to the RE-AIM model that combine to determine the overall public health impact of an intervention. Two factors operate at the level of individual patients: Reach—the percentage and representativeness of patients who are willing to participate in a given procedure, and Efficacy—the impact of an intervention on behavioral, biologic, quality-of-life, and economic outcomes. There are also 2 less often studied but equally important dimensions that have an impact on a medical office or health care system: Adoption—the percentage and representativeness of settings that are willing to adopt an office innovation, and Implementation—the extent to which an intervention is delivered as intended. The fifth dimension, Maintenance, operates at both the individual and system levels. At the individual level, maintenance refers to the extent to which effects are stable long after an intervention is delivered. For this review, we adopted a minimum of a 1-year follow-up as criteria for demonstrating maintenance. At the systems level, maintenance refers to institutionalization of policies and practices such that they become routine.

These 5 factors interact to determine the overall population-based impact of a program. One implication of this model is that an intervention that generally does poorly on 1 or 2 dimensions (ie, fails to reach many patients or is implemented inconsistently) will have low overall public health impact. The RE-AIM evaluation framework was adopted because it relates more to practice-oriented research and real world concerns than other evaluation models and because it places equal emphasis on external validity (generalization) and internal validity, which is helpful in determining how relevant a study is for family practice.