Getting patients to exercise more: A systematic review of underserved populations

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Original Research

Getting patients to exercise more: A systematic review of underserved populations

J Fam Pract. 2008 March;57(3):170-175

By

Jennifer K. Carroll, MD, MPH

Brief counseling and a written plan increase exercise rates in the underserved.

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References

1. Centers for Disease Control and Prevention. Prevalence of physical activity, including lifestyle activities among adults—United States, 2000-2001. MMWR Morb Mortal Wkly Rep 2003;52:764-769.

2. Taylor WC, Baranowski T, Young DR. Physical activity interventions in low-income, ethnic minority, and populations with disability. Am J Prev Med 1998;15:334-343.

3. Crespo CJ, Smit E, Andersen RE, Carter-Pokras O, Ainsworth BE. Race/ethnicity, social class and their relation to physical inactivity during leisure time: results from the Third National Health and Nutrition Examination Survey, 1988-1994. Am J Prev Med 2000;18:46-53.

4. Mainous AG, Diaz VA, Koopman RJ, Everett CJ. Having a regular physician and attempted weight loss after screening for hypertension or hypercholesterolemia. Int J Obes (Lond) 2005;29:223-227.

5. Honda K. Factors underlying variation in receipt of physician advice on diet and exercise: Applications of the behavioral model of health care utilization. Am J Health Promot 2004;18:370-377.

6. Taira DA, Safran DG, Seto TB, Rogers WH, Tarlov AR. The relationship between patient income and physician discussion of health risk behaviors. JAMA 1997;278:1412-1417.

7. Burton LC, Paglia MJ, German PS, Shapiro S, Damiano AM. The effect among older persons of a general preventive visit on three health behaviors: smoking, excessive alcohol drinking, and sedentary lifestyle. The Medicare Preventive Services research Team. Prev Med 1995;24:492-497.

8. Norris SL, Grothaus LC, Buchner DM, Pratt M. Effectiveness of physician-based assessment and counseling for exercise in a staff model HMO. Prev Med 2000;30:513-523.

9. Swinburn BA, Walter LG, Arroll B, Tilyard MW, Russell DG. The green prescription study: a randomized controlled trial of written exercise advice provided by general practitioners. Am J Public Health 1998;88:288-291.

10. Imperial Cancer Research Fund OXCHECK Study Group. Effectiveness of health checks conducted by nurses in primary care: final results of the OXCHECK study. BMJ 1995;310:1099-1104.

11. Bull FC, Kreuter MW, Scharff DP. Effects of tailored, personalized and general health messages on physical activity. Patient Educ Couns 1999;36:181-192.

12. Yancey AK, Kumanyika SK, Ponce NA, McCarthy WM, Fielding JE. Population-based interventions engaging communities of color in healthy eating and active living: a review. Prev Chron Dis 2004;1:1-18.

13. Eden KB, Orleans CT, Mulrow CD, Pender NJ, Teutsch SM. Does counseling by clinicians improve physical activity? A summary of the evidence for the US Preventive Services Task Force. Ann Intern Med 2002;137:208-215.

14. Eakin EG, Glasgow RE, Riley KM. Review of primary care-based physical activity intervention studies: effectiveness and implications for practice and future research. J Fam Pract 2000;49:158-168.

15. Ebell Mh, Siwek J, Weiss BD, et al. Simplifying the language of evidence to improve patient care: Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in medical literature. J Fam Pract 2004;53:111-120.

16. Agurs-Collins TD, Kumanyika SK, Ten Have TR, Adams-Campbell LL. A randomized controlled trial of weight reduction and exercise for diabetes management in older African-American subjects. Diabetes Care 1997;20:1503-1511.

17. Calfas KJ, Long BJ, Sallis JF, Wooten WJ, Pratt M, Patrick K. A controlled trial of physician counseling to promote the adoption of physical activity. Prev Med 1996;25:225-233.

18. Calfas KJ, Sallis JF, Zabinski MF, et al. Preliminary evaluation of a multi-component program for nutrition and physical activity change in primary care: PACE+ for adults. Prev Med 2002;34:153-161.

19. Patrick K, Sallis JF, Prochaska JJ, et al. A multicomponent program for nutrition and physical activity change in primary care: PACE+ for adolescents. Arch Pediatr Adolesc Med 2001;155:940-946.

20. Pinto BM, Goldstein MG, Ashba J, Sciamanna CN, Jette A. Randomized controlled trial of physical activity counseling for older primary care patients. Am J Prev Med 2005;29:247-255.

21. Staten LK, Gregory-Mercado KY, Ranger-Moore J, et al. Provider counseling, health education, and community health workers: The arizona WISEWOMAN project. J Womens Health (Larchmt) 2004;13:547-556.

22. Saelens BE, Sallis JF, Wilfley DE, Patrick K, Cella JA, Buchta R. Behavioral weight control for overweight adolescents initiated in primary care. Obesity Res 2002;10:22-32.

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Practice recommendations

Use focused, brief (2–3 minute) physical activity counseling with patients (B).
Have large-print, easy-to-understand program materials available to supplement your discussion (B). Provide patients with a simple written plan of their physical activity goals (B). Focus on a limited number of concepts to avoid information overload (B).
Address patients’ financial and logistical barriers to participation and adherence (B).
Encourage flexibility in patients’ choices for exercise, and incorporate cultural adaptations (such as preferences for music, dance, or group activities) where appropriate (B).
Use trained support staff, preferably representing the community of interest, to promote physical activity in your patients (B).

Strength of recommendation (SOR)

Good-quality patient-oriented evidence
Inconsistent or limited-quality patient-oriented evidence
Consensus, usual practice, opinion, disease-oriented evidence, case series

Fewer than half of all Americans get sufficient physical activity, defined as 30 minutes or more per day, at least 5 times per week.¹ The need to increase physical activity applies particularly to underserved populations: they are even less likely to get enough physical activity, and are thus even more likely to suffer greater burden of disease.^2,3

The purpose of this systematic review was to assess clinical trials of clinician-initiated counseling interventions for promoting physical activity in under-served populations. We define under-served populations as individuals from minority ethnic backgrounds (such as African Americans, Hispanics, and Asian Americans), or vulnerable populations such as people with low educational attainment, low income, lack of insurance, or those residing in rural communities.

Primary care interventions are linked to a change in habits

Primary care physicians can have a significant impact on their patients’ physical activity. Individuals with a regular primary care physician are more likely to report attempts to change their physical activity habits.⁴ However, underserved populations are more likely to have inconsistent access to medical care, which may contribute to their greater risk of conditions linked to inadequate physical activity, such as diabetes, hypertension, and obesity.

FAST TRACK

These results are promising for primary care physicians, whose relationships with patients afford repeated opportunities to intervene

Only about 25% of patients in primary care settings report receiving any counseling on physical activity.⁵ Those who are middle-aged or have a baccalaureate degree or higher are more likely to report such advice; African Americans and foreign-born immigrants are less likely to report it.

A study by Taira et al⁶ examined the relationship between patient income and discussion of health risk behaviors. Low-income patients were more likely to be obese and smoke than high-income patients; however, physicians were less likely to discuss diet and exercise with low-income patients. Among all the patients with whom some discussion occurred in this study, low-income patients were much more likely to attempt to change behavior based on physician advice than were high-income patients.

Clinical trials within^7,8 and outside the US^9-11 support the potential value of physical activity counseling in primary care. In these studies, as little as 3 to 5 minutes of patient-clinician communication about physical activity was linked to short-term improvement in patients’ exercise habits. As few as 2 or 3 office visits over 6 months were associated with increases in patients’ physical activity levels up to 1 year later. Other features that contributed to their success included having a brief (<3 minutes) counseling component for clinicians, supplementing the counseling with a written exercise prescription, having follow-up contact, and tailoring the counseling to patients’ needs and concerns.

These results are promising for primary care clinicians, whose longitudinal relationships with their patients afford them repeated opportunities to intervene to promote physical activity.

Few studies have focused on the underserved

A review by Taylor et al² of physical activity interventions in low-income, ethnic minority, or disabled populations identified 14 community-based studies, mostly with quasi-experimental “pre/post” study designs. Ten studies included ethnic minorities, but physical activity was documented in just 2 studies at baseline, and these 2 studies did not include any postintervention follow-up. None of the 10 interventions was conducted in a primary care setting.

Another recent review¹² found that studies that were ethnically inclusive placed greater emphasis on involving communities and building coalitions right from study inception, and they tailored messages (and messengers) that were culturally specific. Several of these studies showed better outcomes among ethnic minority participants than the white participants they sampled.

FAST TRACK

We looked at trials where counseling was initiated in primary care, and that looked at changes in patients’ physical activity

Taken together, previous reviews have examined the effectiveness of primary care interventions for the general population,^13,14 as well as community-based programs for underserved populations.² However, little information exists about effective physical activity counseling strategies for underserved groups in primary care.