Although we sought trials that defined “primary care clinician” as a professional—such as MD, nurse practitioner (NP), or physician assistant (PA)—who provides longitudinal primary health care, several of these studies considered dieticians, exercise physiologists, or health care workers as primary care clinicians.
Only 1 study20 examined physical activity counseling with an intervention that incorporated a follow-up visit by the primary care clinician, and looked at the long-term effect on physical activity as an outcome. Thus, the degree to which the clinician’s counseling influenced the physical activity outcome in these studies is unclear.
The “dose” of clinician counseling varied from very brief (1 to 3 minutes of direct contact on 1 occasion) to more extended (>5 minutes of direct counseling over repeated intervals). Duration of follow-up for the 8 studies ranged from 4 months to 2 years.
Several studies designed their interventions to make the clinician counseling brief,17-20,23 in order to enhance feasibility for busy primary care settings. Three studies16,21,22 described strategies they used for tailoring the intervention to a specific culture, or for addressing issues of literacy for the written materials. Two studies16,22 reported that their study staffs were ethnically or culturally representative of the targeted population.
Three studies18,19,21 reported having difficulty with attrition among their minority participants; they did not, however, include information specific to minorities in their physical activity outcomes. Studies with highest retention rates (>80%) tended to specifically address barriers to participation, including cultural issues, or they used a “lead-in” period.16,20,21,23
The studies with the best adherence and retention among black and Hispanic participants, and those participants with low educational attainment,16,21 used baseline qualitative data regarding management of health behaviors when they designed their interventions. For example, 1 study16 mentioned cultural adaptations derived from prior qualitative work—such as using program materials that extensively depicted African American individuals, families, and community settings—and using language in the intervention reflecting social values and situations relevant to African Americans.
Six of the 8 (75%) studies16,17,19,20,22,23 reported some improvement in short-term physical activity outcomes (TABLE 2, available at www.jfponline.com); however, there was considerable heterogeneity in how these studies measured physical activity outcomes. All 8 incorporated a self-report measure of physical activity, such as the Patient-centered Assessment and Counseling for Exercise (PACE),17-19 Paffenbarger Physical Activity Questionnaire (PPAQ),17 7-day Physical Activity Recall (PAR),17,20,21,23 and other self-report recall measures to assess physical activity. (A RESOURCE LIST of these instruments is available at www.jfponline.com.) Two studies also measured “states of change,”17,20 but these states were not consistently defined.
Three studies17,20,23 included objective measures of physical activity, such as accelerometers; in these studies, there was not substantial variance in physical activity outcomes between the objective and subjective measures.
This review reflects in part the difficult task of designing and implementing realistic interventions for the underserved in primary care. However, interventions must be replicated in these populations before we can necessarily assume that findings from other trials are generalizable, due to issues of access, financial resources, health literacy, beliefs, cultural differences, self-efficacy, and other logistic barriers to traditional care that disproportionately affect underserved groups.
Several studies24-26 have explored the social, demographic, and environmental factors associated with physical activity in minority populations. These studies shed light on the reasons why clinical trials that focus on white, affluent, educated populations might not be generalizable to underserved groups.
To be maximally effective, any interventions for promoting physical activity in the underserved need to find ways to address any cultural or financial barriers, and incorporate factors associated with success. For example, among African American and Hispanic women, having lower “social role strain,” higher attendance at religious services, and a greater feeling that one’s neighborhood was safe were all associated with increased likelihood of exercise.24-26 Such studies suggest that differences in beliefs, resources, self-efficacy, prior experience, and competing life demands can all contribute to promoting physical activity in some underserved groups. Practically, such findings encourage clinicians to work with patients to help them identify sources of social support and positive influences on their health, and help them articulate internal strengths and personal attributes to succeed in behavioral change.
Despite the variations in training or means of communication in the studies we identified, 2 studies used interventions that were successful at explicitly anticipated and addressed barriers to physical activity.16,21 These 2 studies also had interventionists who represented the communities of interest, and they used cultural adaptations to promote exercise where appropriate. Thus, limited data suggest that some primary care–based programs improve physical activity in underserved patients, but the effects of communication from the primary care clinician on physical activity is lacking, consistent with other work in the field.12,27
Primary care clinicians face many time pressures, fiscal constraints, administrative burdens, and competing priorities; these make addressing health promotion behaviors such as physical activity quite difficult. These issues are magnified for clinicians practicing in medically underserved areas. Despite these many challenges, promising opportunities do exist.
On a systems level, practice-based systems to manage chronic diseases have been successfully developed and implemented in the primary care setting; such systems can be tested to promote physical activity, as well. These practice-based approaches include patient registry data, office prompts, and other electronic systems to promote clinician counseling. For example, studies in this review using computer-based programs in primary care offices were feasible and effective.18,19,21
Bodenheimer28 has argued for a redesign of primary care systems to more effectively address chronic conditions rather than acute care needs. Several health care systems have successfully implemented the pillars of such a redesign imperative, and they have shown convincingly the promise of addressing competing priorities, physician competence and confidence, motivation, and durability in improving patient self-management.28
At the level of the clinician-patient relationship, data suggest that patient physical activity can be increased (at least in the short term) by counseling that:
We do not know what “dose-response” relationship exists for primary care clinician communication with patients over the long term, and what effect repeated counseling would have on long-term sustainability of physical activity levels. This is even less clear for underserved groups. It is also unknown to what extent collaborative links with community programs might increase physical activity when added to primary care–based counseling. Future research should evaluate the optimal “dose-response” to the interventions, the effect of repeated visits and continuity of care, and the effect of community-based referrals for physical activity programs for underserved populations in primary care.
Because our inclusion criteria were strict, we omitted potentially meaningful studies that were less directly relevant to our aims. For example, there has been substantial creative community-based work with underserved populations in the US to promote physical activity, and many innovations have been designed by researchers outside the US. Results from these programs and trials should be incorporated into primary care settings working with underserved populations.
Another limitation is that our definition of “underserved” is not the only possible definition. The most marginalized underserved groups with the least access to the health care system (such as the uninsured or homeless) were more likely to be omitted from our results, because we wanted to examine physical activity programs among patients in primary care settings.
Finally, this review did not address the need to understand the connection between sustained improvements in physical activity and patient-oriented health outcomes for underserved populations.
Information on exercise counseling interventions in primary care for the underserved is limited: these groups have not been included in the majority of clinical trials of physical activity thus far. Physical activity interventions need to be replicated in underserved populations before we can assume their results are generalizable. Though characteristics of existing studies show promise, future research on physical activity in underserved populations should assess the effect of practice-based systems on reducing barriers and promoting physical activity, the dose-response effect of clinician counseling on physical activity outcomes, and the effect of the physician-patient relationship and continuity of care on physical activity outcomes.
This study was supported by grant 1R25CA102618 from the National Cancer Institute.
The authors reported no potential conflict of interest relevant to this article.
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Correspondence Jennifer K. Carroll, MD, MPH, University of Rochester School of Medicine, Family Medicine Research Programs, 1381 South Avenue, Rochester, NY 14620; email@example.com
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