Training physicians to conduct physical activity counseling

Implementation of evidence-based primary cancer prevention interventions in MA community health centers: an explanatory sequential mixed methods study

BACKGROUND

More than half of cancers could be prevented by employing evidence-based interventions (EBIs), including prevention interventions targeting nutrition, physical activity, and tobacco. Federally qualified health centers (FQHCs) are the primary source of patient care for over 30 million Americans - making them an optimal setting for ensuring evidence-based prevention that advances health equity. The aims of this study are to (1) determine the degree to which primary cancer prevention EBIs are being implemented within Massachusetts FQHCs and (2) describe how these EBIs are implemented internally and via community partnerships.

METHODS

We used an explanatory sequential mixed methods design to assess the implementation of cancer prevention EBIs. First, we collected 34 quantitative surveys from staff at 16 FQHCs across Massachusetts to determine the frequency of EBI implementation. We followed up with 12 qualitative one-on-one interviews among a sample of staff to understand how the EBIs selected on the survey were implemented. Exploration of contextual influences on implementation and use of partnerships was guided by the Consolidated Framework for Implementation Research (CFIR). Quantitative data were summarized descriptively, and qualitative analyses used reflexive, thematic approaches, beginning deductively with codes from CFIR, then inductively coding additional categories.

RESULTS

All FQHCs indicated they offered clinic-based tobacco interventions, such as clinician-delivered screening practices and prescription of tobacco cessation medications. Quitline interventions and some diet/physical activity EBIs were available at all FQHCs, but staff perceptions of penetration were low. Only 38% of FQHCs offered group tobacco cessation counseling and 63% referred patients to mobile phone-based cessation interventions. We found multilevel factors influenced implementation across intervention types - including the complexity of intervention trainings, available time and staffing, motivation of clinicians, funding, and external policies and incentives. While partnerships were described as valuable, only one FQHC reported using clinical-community linkages for primary cancer prevention EBIs.

CONCLUSIONS

Adoption of primary prevention EBIs in Massachusetts FQHCs is relatively high, but stable staffing and funding are required to successfully reach all eligible patients. FQHC staff are enthusiastic about the potential of community partnerships to foster improved implementation-providing training and support to build these relationships will be key to fulfilling that promise.

Determinants of adherence to antihypertensive treatment among patients attending a primary care clinic with limited medical armamentarium in Delhi, India: A qualitative study

OBJECTIVE

To determine perspectives on reasons for non-adherence to antihypertensive therapy and its socioeconomic determinants among patients attending a primary care center in a low-income area in Delhi, India.

METHODS

We conducted in-depth interviews with a total of 30 patients having hypertension at a primary care facility located in a low-income urban area in Delhi.

RESULTS

All the participants were aware that hypertension was a serious illness, and medication intake was necessary throughout life to prevent uncontrolled hypertension. All participants in varying quantities practiced salt restriction, but the consumption of fresh fruit and vegetables was low primarily due to economic reasons. The participants were unable to differentiate the concept of exercise from physical activity. Medication adherence was suboptimal, and significant reasons for non-adherence were forgetfulness, carelessness and running out of drug stocks. Blood pressure control was also suboptimal in a majority of the participants, but combination therapy was restricted due to limited medical armamentarium at the clinic. Laboratory investigations for monitoring target end-organ damage were either delayed or not conducted in most participants.

DISCUSSION

Hypertensive patients undergoing treatment at primary care facilities often report suboptimal medical adherence and treatment outcomes, with socioeconomic causes being a major driver of non-adherence.

Does Health Professional Counseling Impact the Quality-of-Life Levels of Older Adults Enrolled in Physical Activity Programs?

Background and objectives: There are studies showing that exercise counseled by health professionals can improve physical fitness. However, less is known about the effects of exercise counseling on quality of life. The aim of this study was to investigate health-related quality of life of older adults who received or did not receive physical exercise counseling by sport and exercise professionals or physicians. Materials and Methods: This was a cross-sectional study that investigated quality of life of older adults who did or did not receive exercise counseling from health professionals. Older adults who were physically active took part in this study: 45 participants performed exercise advised by sport and exercise professionals (SEPCG), 19 participants performed exercise advised by physicians (PCG), and 26 participants performed exercise without counseling (NCG). Participants answered the SF-36 to estimate quality of life. Results: Analysis revealed that responses on all SF-36 subscales were higher in those participants who received counseling by sport and exercise professionals (Functioning capacity, β = -26.283, p < 0.001 and β = -26.482, p < 0.001, Role limitations due to physical problems, β = -43.372, p < 0.001 and β = -45.177, p < 0.001, Pain, β = -17.634, p < 0.001 and β = -16.015, p < 0.001, General health perceptions, β = -38.008, p < 0.001 and β = -32.529, p < 0.001, Vitality, β = -18.573, p < 0.001 and β = -16.406, p = 0.001, Social functioning, β = -37.963, p < 0.001 and β = -29.224, p < 0.001, Role limitations due to emotional problems, β = -52.246, p < 0.001 and β = -40.173, p < 0.001, Mental health, β = -17.381, p < 0.001 and β = -12.121, p < 0.001, PCG and NCG respectively). Conclusions: The results showed that those older adults who were counseled by sport and exercise professionals presented better quality of life, possibly because these professionals counseled exercise based on current guidelines for exercise prescription.

Perceptions and Practices of Providing Physical Activity Counselling and Exercise Prescriptions among Physiotherapists in Nova Scotia

Purpose: We assessed the perceptions and practices of physical activity counselling and exercise prescription of physiotherapists in Nova Scotia. Method: A total of 146 physiotherapists in Nova Scotia completed an online self-reflection survey regarding their current practice of, confidence in, barriers to, and facilitators of providing physical activity and exercise (PAE) counselling to their patients. Results: Physiotherapists included physical activity counselling and exercise content in 85% of patient counselling appointments. They reported a high level of confidence (> 90%) in providing PAE information and answering patients' PAE questions and moderate confidence in their patients' abilities to maintain PAE over the long term (73%) and to follow through on their PAE recommendations (66%). Patients' interest in PAE was the greatest barrier to providing PAE counselling. The physiotherapists reported being most comfortable when prescribing exercise for patients with musculoskeletal conditions and least comfortable with patients with cancer, insulin-dependent diabetes, and respiratory conditions. Most physiotherapists (71%) reported being interested in pursuing further education or training in PAE counselling and prescription. Conclusions: The physiotherapists frequently recommended PAE to their patients, had moderate confidence in their patients' ability to follow through on their advice, and experienced patients' disinterest in PAE as the greatest barrier to providing PAE counselling. The results of this study suggest a desire by physiotherapists for educational training opportunities, which we recommend be focused on providing behavioural strategies and further information to help overcome patient-focused barriers; this will help patients adopt and maintain physically active lifestyles.

Self-Report Tools for Assessing Physical Activity in Community-Living Older Adults with Multiple Chronic Conditions: A Systematic Review of Psychometric Properties and Feasibility

Identifier l'outil d'autodéclaration de l'activité physique (AP) le plus adapté pour l'évaluation de l'AP chez les personnes âgées vivant dans la communauté qui sont atteintes de multiples maladies chroniques (MMC). L'AP peut avoir une influence positive sur la santé physique et psychologique de cette population. Bien qu'il existe des outils d'auto-évaluation de l'AP, les propriétés psychométriques et la faisabilité de l'utilisation de ces outils chez les personnes âgées avec MMC sont peu connues. Une revue systématique des études publiées entre 2000 et 2018 portant sur les propriétés psychométriques et la faisabilité de 18 outils d'auto-évaluation élaborés pour les personnes âgées vivant en communauté (≥ 65 ans) a été réalisée en vue de déterminer leur pertinence pour les personnes âgées atteintes de MMC. L'évaluation des données disponibles sur les propriétés psychométriques et la faisabilité des 18 outils d'auto-évaluation de l'activité physique a permis d'établir que l'Échelle d'évaluation de l'activité physique chez les personnes âgées (Physical Activity Assessment Scale for the Elderly; PASE) est l'outil d'auto-évaluation le plus adapté, qui devrait être recommandé pour la population de personnes âgées avec MMC.

The purpose of this study was to identify the self-report physical activity (PA) tool best suited for assessment of PA in community-dwelling older adults with multiple chronic conditions (MCC). PA can positively influence physical and psychological health in this population. Although self-report PA tools exist, little is known about the psychometric properties and feasibility of using these tools in older adults with MCC. A systematic literature review from 2000 to 2018 was conducted of studies reporting on the psychometric properties and feasibility of 18 self-report PA tools for community-dwelling older adults (≥ 65 years) to determine the suitability of these tools for use in older adults with MCC. Based on an assessment of the available evidence for the psychometric properties and feasibility of 18 different self-report PA tools, the Physical Activity Assessment Scale for the Elderly (PASE) is recommended as the best-suited self-report PA tool for older adults with MCC.

Evaluating the effectiveness of physician counseling to promote physical activity in Mexico: an effectiveness-implementation hybrid study

Integrating physical activity (PA) counseling in routine clinical practice remains a challenge. The purpose of this study was to evaluate the implementation and effectiveness of a pragmatic strategy aimed to improve physician PA counseling and patient PA. An effectiveness-implementation type-2 hybrid design was used to evaluate a 3-h training (i.e., implementation strategy-IS) to increase physician use of the 5-As (assess, advise, agree, assist, arrange) for PA counseling (i.e., clinical intervention-CI) and to determine if the CI improved patient PA. Patients of trained and untrained physicians reported on PA and quality of life pre-post intervention. Medical charts (N = 1700) were examined to assess the proportion of trained physicians that used the 5-As. The RE-AIM framework informed our evaluation. 305/322 of eligible physicians participated in the IS (M age = 40 years, 52% women) and 683/730 of eligible patients in the CI (M age = 49 years, 77% women). The IS was adopted by all state regions and cost ~ $20 Mexican pesos (US$1) per provider trained. Physician adoption of any of the 5-As improved from pre- to post-training (43 vs. 52%, p < .01), with significant increases in the use of assessment (43 vs. 52%), advising (25 vs. 39%), and assisting with barrier resolution (7 vs. 15%), but not in collaborative goal setting (13 vs. 17%) or arranging for follow-up (1 vs. 1%). Patient PA and quality of life did not improve. The IS intervention was delivered with high fidelity at a low cost, but appears to be insufficient to lead to broad adoption of the CI.

Electronic monitoring of adherence to inhaled corticosteroids: an essential tool in identifying severe asthma in children

International guidelines recommend that severe asthma can only be diagnosed after contributory factors, including adherence, have been addressed. Accurate assessment of adherence is difficult in clinical practice. We hypothesised that electronic monitoring in children would identify nonadherence, thus delineating the small number with true severe asthma.Asthmatic children already prescribed inhaled corticosteroids were prospectively recruited and persistence of adherence assessed using electronic monitoring devices. Spirometry, airway inflammation and asthma control were measured at the start and end of the monitoring period.93 children (62 male; median age 12.4 years) were monitored for a median of 92 days. Median (range) monitored adherence was 74% (21-99%). We identified four groups: 1) good adherence during monitoring with improved control, 24% (likely previous poor adherence); 2) good adherence with poor control, 18% (severe therapy-resistant asthma); 3) poor adherence with good control, 26% (likely overtreated); and 4) poor adherence with poor control, 32%. No clinical parameter prior to monitoring distinguished these groups.Electronic monitoring is a useful tool for identifying children in whom a step up in treatment is indicated. Different approaches are needed in those who are controlled when adherent or who are nonadherent. Electronic monitoring is essential in a paediatric severe asthma clinic.

What do we know about brief interventions for physical activity that could be delivered in primary care consultations? A systematic review of reviews

This systematic review of reviews aims to investigate how brief interventions (BIs) are defined, whether they increase physical activity, which factors influence their effectiveness, who they are effective for, and whether they are feasible and acceptable. We searched CINAHL, Cochrane database of systematic reviews, DARE, HTA database, EMBASE, MEDLINE, PsycINFO, Science Citation Index-Expanded and Social Sciences Citation Index, and Scottish Intercollegiate Guidelines Network from their inception until May 2015 to identify systematic reviews of the effectiveness of BIs aimed at promoting physical activity in adults, reporting a physical activity outcome and at least one BI that could be delivered in a primary care setting. A narrative synthesis was conducted. We identified three specific BI reviews and thirteen general reviews of physical activity interventions that met the inclusion criteria. The BI reviews reported varying definitions of BIs, only one of which specified a maximum duration of 30min. BIs can increase self-reported physical activity in the short term, but there is insufficient evidence about their long-term impact, their impact on objectively measured physical activity, and about the factors that influence their effectiveness, feasibility and acceptability. Current definitions include BIs that are too long for primary care consultations. Practitioners, commissioners and policy makers should be aware of this when interpreting evidence about BIs, and future research should develop and evaluate very brief interventions (of 5min or less) that could be delivered in a primary care consultation.

Health care provider confidence and exercise prescription practices of Exercise is Medicine Canada workshop attendees

The Exercise is Medicine Canada (EIMC) initiative promotes physical activity counselling and exercise prescription within health care. The purpose of this study was to evaluate perceptions and practices around physical activity counselling and exercise prescription in health care professionals before and after EIMC training. Prior to and directly following EIMC workshops, 209 participants (physicians (n = 113); allied health professionals (AHPs) (n = 54), including primarily nurses (n = 36) and others; and exercise professionals (EPs) (n = 23), including kinesiologists (n = 16), physiotherapists (n = 5), and personal trainers (n = 2)) from 7 provinces completed self-reflection questionnaires. Compared with AHPs, physicians saw more patients (78% > 15 patients/day vs 93% < 15 patients/day; p < 0.001) and reported lower frequencies of exercise counselling during routine client encounters (48% vs 72% in most sessions; p < 0.001). EPs had higher confidence providing physical activity information (92 ± 11%) compared with both physicians (52 ± 25%; p < 0.001) and AHPs (56 ± 24%; p < 0.001). Physicians indicated that they experienced greater difficulty including physical activity and exercise counselling into sessions (2.74 ± 0.71, out of 5) compared with AHPs (2.17 ± 0.94; p = 0.001) and EPs (1.43 ± 0.66; p < 0.001). Physicians rated the most impactful barriers to exercise prescription as lack of patient interest (2.77 ± 0.85 out of 4), resources (2.65 ± 0.82 out of 4), and time (2.62 ± 0.71 out of 4). The majority of physicians (85%) provided a written prescription for exercise in <10% of appointments. Following the workshop, 87% of physician attendees proposed at least one change to practice; 47% intended on changing their practice by prescribing exercise routinely, and 33% planned on increasing physical activity and exercise counselling, measured through open-ended responses.

State of the Art Review: Promoting Physical Activity in Primary Care Settings: A Review of Cognitive and Behavioral Strategies

Despite recognition that physical activity is associated with numerous health benefits, many Americans do not meet current guidelines for physical activity. Primary care providers are in a unique position to influence physical activity, though conflicting evidence exists regarding the effectiveness of primary care—based physical activity promotion. The present article provides a qualitative review of the literature on physical activity promotion within primary care settings, focusing specifically on types of cognitive and behavioral intervention strategies that can be implemented into routine practice by primary care providers. The authors searched MEDLINE and identified 16 studies that met relevant experimental, intervention, and outcome criteria. Intervention types were defined as those involving education, advice, self-monitoring, face-to-face counseling, and telephone follow-up. Most interventions included multiple components. Within the limitations of the review, results suggest that a variety of interventions are effective at increasing physical activity and/or fitness of middle-aged and older adults, among both men and women. More research is needed to determine which interventions are most effective in which doses and combinations, with ethnic minorities and younger adults, and regarding long-term outcomes.

A randomised controlled trial of three very brief interventions for physical activity in primary care

Background

Very brief interventions (VBIs) for physical activity are promising, but there is uncertainty about their potential effectiveness and cost. We assessed potential efficacy, feasibility, acceptability, and cost of three VBIs in primary care, in order to select the most promising intervention for evaluation in a subsequent large-scale RCT.

Methods

Three hundred and ninety four adults aged 40–74 years were randomised to a Motivational (n = 83), Pedometer (n = 74), or Combined (n = 80) intervention, delivered immediately after a preventative health check in primary care, or control (Health Check only; n = 157). Potential efficacy was measured as the probability of a positive difference between an intervention arm and the control arm in mean physical activity, measured by accelerometry at 4 weeks.

Results

For the primary outcome the estimated effect sizes (95 % CI) relative to the Control arm for the Motivational, Pedometer and Combined arms were respectively: +20.3 (−45.0, +85.7), +23.5 (−51.3, +98.3), and −3.1 (−69.3, +63.1) counts per minute. There was a73% probability of a positive effect on physical activity for each of the Motivational and Pedometer VBIs relative to control, but only 46 % for the Combined VBI. Only the Pedometer VBI was deliverable within 5 min. All VBIs were acceptable and low cost.

Conclusions

Based on the four criteria, the Pedometer VBI was selected for evaluation in a large-scale trial.

Trial registration

Current Controlled Trials ISRCTN02863077. Retrospectively registered 05/10/2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3684-7) contains supplementary material, which is available to authorized users.

Factors Underlying Variation in Receipt of Physician Advice on Diet and Exercise: Applications of the Behavioral Model of Health Care Utilization

Purpose.

To identify factors associated with receipt of physician advice on diet and exercise, including patient sociodemographic characteristics, health-related needs, and health care access, using Andersen's model of health care utilization.

Design.

A cross-sectional analysis was performed using data from the 2000 National Health Interview Survey (NHIS).

Setting.

NHIS data were collected through personal household interviews by Census interviewers. The overall response rate for the 2000 NHIS adult sample was 82.6%.

Subjects.

Subjects were a representative sample of the American civilian, noninstitutionalized population aged 18 and older. After eliminating missing data and respondents who reported they did not see a doctor in the past 12 months, sample sizes for physician advice on diet and exercise were n = 26,255 and n = 26,158, respectively.

Measures.

Using the 2000 NHIS, the prevalence of receipt of physician advice on diet and exercise was assessed. Multiple logistic regression analyses were performed to examine the associations between receipt of physician advice on diet and exercise and potential predictors, adjusting for all covariates.

Results.

By self-report, 21.3% and 24.5% of respondents received physician advice on diet and exercise, respectively. Being middle-aged (adjusted odds ratio [AOR] = 1.14, 95% confidence interval [CI], 1.0–1.29 for diet; AOR = 1.55, 95% CI = 1.33–1.79 for exercise) and having a baccalaureate degree or higher (AOR = 1.78, 95% CI = 1.52–2.08 for diet; AOR = 1.75, 95% CI = 1.47–2.07) were associated with a higher likelihood of receiving physician advice on diet and exercise. African-Americans (AOR = .78, 95% CI = .67–.92) and foreign-born immigrants (AOR = .57, 95% CI = .38–.86) were less likely to receive physician advice on exercise. The prevalence of physician advice was higher for persons who chose hospital outpatient departments as a usual source for care (AOR = 2.36, 95% CI = 1.66–3.36 for diet; AOR = 2.39, 95% CI = 1.68–3.4 for exercise) than for adults with other types of usual care sites. Poorer self-rated health status (AOR = 5.2, 95% CI = 4.12–6.57 for diet; AOR = 2.63, 95% CI = 2.04–3.38 for exercise) and obesity (AOR = 2.32, 95% CI = 2.02–2.66 for diet; AOR = 3.01, 95% CI = 2.46–3.69 for exercise) was positively associated with the likelihood of receiving physician advice on diet and exercise.

Conclusions.

Effective strategies to increase receipt of physician advice should include efforts to improve access to regular source of care and patient-physician communication. Sociodemographic factors remain independent and important predictors of who obtains such advice.

Interventions to promote or maintain physical activity during and after the transition to retirement: an evidence synthesis

Background

It has been argued that transition points in life, such as the approach towards and early years of retirement, present key opportunities for interventions to improve the health of the population. Interventions that may change or preserve activity levels around the time of retirement have the potential to provide benefits in terms of increased health and well-being for people in later life. Research has highlighted health inequalities in health statuses in the retired population and in response to interventions.

Objective

We aimed to conduct a systematic review and meta-synthesis of the types and effectiveness of interventions to increase physical activity among people around the time of retirement. We also aimed to identify factors that may underpin the effectiveness or acceptability of interventions, and how issues of health inequalities may be addressed.

Data sources

The following electronic databases were searched: (1) MEDLINE; (2) Applied Social Sciences Index and Abstracts; (3) The Cochrane Library (including The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database); (4) Cumulative Index to Nursing and Allied Health Literature; (5) Science Citation Index; (6) Social Science Citation Index; (7) PsycINFO; (8) Evidence for Policy and Practice Information and Co-ordinating Centre; (9) SPORTDiscus; (10) Social Policy and Practice; (11) Health Management Information Consortium; and (12) Sociological Abstracts. We also searched for grey literature, checked reference lists of included papers and screened other reviews.

Review methods

A systematic review of quantitative and qualitative literature was carried out between February 2014 and April 2015. The searches aimed to identify, first, evidence of effectiveness of interventions for older adults at the point of transition to retirement and, second, data relating to perceptions of barriers and facilitators to intervention effectiveness. A meta-synthesis of the two types of evidence was also carried out to provide further interpretation of the review findings.

Results

A systematic search of the literature identified a large number of potentially relevant studies. Of these, 103 studies examining the effectiveness of interventions and 55 qualitative papers met the criteria for inclusion. A review of the effectiveness literature indicated a dearth of studies that investigate interventions that specifically examine the transition to retirement. More general studies in older adults indicated that a range of interventions might be effective for people around retirement age. The qualitative literature indicated the importance of considering the appeal and enjoyment, and social aspects, of interventions. Although there were a range of different measures in use, many were self-reported and few studies included an evaluation of sedentary time. A meta-synthesis across the data types indicated that elements reported as significant by participants did not always feature in the interventions.

Limitations

Owing to the lack of evidence relating to the retirement transition, we examined the literature relating to older adults. The applicability of these data to people around retirement age may need consideration.

Conclusions

Although the retirement transition is considered a significant point of life change, only a small volume of literature has reported interventions specifically in this period. The included literature suggests that interventions should take account of views and preferences of the target population and evaluate effectiveness by measuring meaningful outcomes and using a control group design.

Study registration

This study is registered as PROSPERO CRD42014007446.

Funding

The National Institute for Health Research Public Health Research programme.

Promoting and maintaining physical activity in the transition to retirement: a systematic review of interventions for adults around retirement age

It has been argued that transition points in life, such as the approach towards, and early years of retirement present key opportunities for interventions to improve the health of the population. Research has also highlighted inequalities in health status in the retired population and in response to interventions which should be addressed. We aimed to conduct a systematic review to synthesise international evidence on the types and effectiveness of interventions to increase physical activity among people around the time of retirement. A systematic review of literature was carried out between February 2014 and April 2015. Searches were not limited by language or location, but were restricted by date to studies published from 1990 onwards. Methods for identification of relevant studies included electronic database searching, reference list checking, and citation searching. Systematic search of the literature identified 104 papers which described study populations as being older adults. However, we found only one paper which specifically referred to their participants as being around the time of retirement. The intervention approaches for older adults encompassed: training of health care professionals; counselling and advice giving; group sessions; individual training sessions; in-home exercise programmes; in-home computer-delivered programmes; in-home telephone support; in-home diet and exercise programmes; and community-wide initiatives. The majority of papers reported some intervention effect, with evidence of positive outcomes for all types of programmes. A wide range of different measures were used to evaluate effectiveness, many were self-reported and few studies included evaluation of sedentary time. While the retirement transition is considered a significant point of life change, little research has been conducted to assess whether physical activity interventions at this time may be effective in promoting or maintaining activity, or reducing health inequalities. We were unable to find any evidence that the transition to retirement period was, or was not a significant point for intervention. Studies in older adults more generally indicated that a range of interventions might be effective for people around retirement age.

General practitioner-delivered adherence counseling in asthma: feasibility and usefulness of skills, training and support tools

OBJECTIVE

Poor medication adherence contributes to uncontrolled asthma in primary care. Good doctor-patient communication around adherence increases patients' medication taking but general practitioners (GPs) often feel poorly equipped to provide effective adherence counseling. This study aimed to assess the feasibility and usefulness of adherence counseling training, skills and support tools for GPs.

METHODS

Twenty-five GPs enrolled in a 6-month cluster randomized-controlled trial of adherence interventions for asthma were randomized to an intervention delivering personalized adherence discussions. They received 2 hours training in delivering brief, motivational-interviewing-based adherence counseling and were provided with asthma-specific counseling support tools. At baseline, post-training and study end, GPs rated the training, reported confidence/frequency of using counseling skills and satisfaction with their consultations, and commented on support tools. Patients reported their barriers to adherence and rated their GPs empathy at baseline and at 6-months.

RESULTS

96% of GPs rated adherence counseling training as very/extremely useful. At the end of the study (17 ± 4 months) GPs' confidence in using counseling skills increased, as did the frequency they applied the skills and their satisfaction with consultations. GPs were positive about counseling support tools, stating that they were easy to use and facilitated covering more ground within single consultations. Half the GPs expressed some difficulty implementing counseling due to time constraints. Patients reported good GP empathy and no significant change in adherence barriers.

CONCLUSIONS

GPs valued counseling training and support tools. Although implementation was sometimes challenging, GPs reported increased frequency of use and confidence in applying adherence counseling skills, which persisted for 17 months.

Inhaler reminders improve adherence with controller treatment in primary care patients with asthma

BACKGROUND

Poor adherence contributes to uncontrolled asthma. Pragmatic adherence interventions for primary care settings are lacking.

OBJECTIVE

To test the effectiveness of 2 brief general practitioner (GP)-delivered interventions for improving adherence and asthma control.

METHODS

In a 6-month cluster randomized 2 × 2 factorial controlled trial, with GP as unit of cluster, we compared inhaler reminders and feedback (IRF) and/or personalized adherence discussions (PADs) with active usual care alone; all GPs received action plan and inhaler technique training. GPs enrolled patients prescribed combination controller inhalers, with suboptimal Asthma Control Test (ACT) scores (ACT score ≤19). Inhaler monitors recorded fluticasone propionate/salmeterol adherence (covertly for non-IRF groups) and, in IRF groups, provided twice-daily reminders for missed doses, and adherence feedback. PAD GPs received communication training regarding adherence. Outcomes collected every 2 months included ACT scores (primary outcome) and severe exacerbations. Intention-to-treat mixed-model analysis incorporated cluster effect and repeated measures.

RESULTS

A total of 43 GPs enrolled 143 patients with moderate-severe asthma (mean age, 40.3 ± 15.2 years; ACT score, 14.6 ± 3.8; fluticasone propionate dose, 718 ± 470 μg). Over 6 months, adherence was significantly higher in the IRF group than in non-IRF groups (73% ± 26% vs 46% ± 28% of prescribed daily doses; P < .0001), but not between PAD and non-PAD groups. Asthma control improved overall (mean change in ACT score, 4.5 ± 4.9; P < .0001), with no significant difference among groups (P = .14). Severe exacerbations were experienced by 11% of the patients in IRF groups and 28% of the patients in non-IRF groups (P = .013; after adjustment for exacerbation history; P = .06).

CONCLUSIONS

Inhaler reminders offer an effective strategy for improving adherence in primary care compared with a behavioral intervention or usual care, although this may not be reflected in differences in day-to-day asthma control.

Physical activity counseling in primary health care in Brazil: a national study on prevalence and associated factors

Background

The aim of this study was to determine the prevalence and correlates of physical activity counseling among physicians and nurses working in primary health care in Brazil.

Methods

A phone survey was carried out in 2011 with professionals working in primary health care in Brazil. The target sample consisted of 1,600 randomly selected primary care units covering all regions of the country. We successfully interviewed 529 professionals within the sampled units; 182 physicians and 347 nurses. The overall response rate was 49.6%. Multivariable logistic regression was used to estimate correlates of counseling in the whole sample and separately for physicians and nurses.

Results

The prevalence of regular physical activity counseling for at least six months was 68.9% (95% CI 64.9; 72.8) and was significantly higher among physicians compared to nurses (p < 0.05). Most professionals (93.2%) interviewed were unfamiliar with current physical activity recommendations for health. In the adjusted analysis, physical activity counseling was more frequent among those who report assessing patient’s physical activity (OR = 2.16; 95% CI 1.41; 3.29), those reporting that lack of time was not a barrier for counseling (OR = 0.62 95% CI 0.42-0.93), those who felt prepared to provide physical activity counseling (OR = 2.34; 95% CI 1.50-3.66), and those working at primary care units offering physical activity programs for patients (OR = 2.06; 95% CI 1.33-3.20). In the stratified analysis, only assessing patient’s physical activity was a significant correlate among physicians whereas assessing patient’s physical activity, feeling prepared to provide counseling and working in units with physical activity interventions were significant correlates among nurses.

Conclusions

Physicians and nurses deemed physical activity counseling of great importance in primary health care in Brazil. However, in order to increase the quality of counseling and the number of professionals engaging in this activity, these health teams require greater knowledge about physical activity (global recommendations for health) as well as training on the application of instruments for assessing physical activity. Moreover, sufficient time must be allowed during consultations for the counseling process, and physical activity promotion programs should be implemented within the primary health care units.

HIV intervention for providers study: a randomized controlled trial of a clinician-delivered HIV risk-reduction intervention for HIV-positive people

Clinician-delivered prevention interventions offer an opportunity to integrate risk-reduction counseling as a routine part of medical care. The HIV Intervention for Providers study, a randomized controlled trial, developed and tested a medical provider HIV prevention training intervention in 4 northern California HIV care clinics. Providers were assigned to either the intervention or control condition (usual care). The intervention arm received a 4-hour training on assessing sexual risk behavior with HIV-positive patients and delivering risk-reduction-oriented prevention messages to patients who reported risk behaviors with HIV-uninfected or unknown-status partners. To compare the efficacy of the intervention versus control on transmission risk behavior, 386 patients of the randomized providers were enrolled. Over six-months of follow-up, patients whose providers were assigned the intervention reported a relative increase in provider-patient discussions of safer sex (OR = 1.49; 95% CI = 1.06 to 2.09), assessment of sexual activity (OR = 1.60; 95% CI = 1.05 to 2.45), and a significant decrease in the number of sexual partners (OR = 0.49, 95% CI = 0.26 to 0.92). These findings show that a brief intervention to train HIV providers to identify risk and provide a prevention message results in increased prevention conversations and significantly reduced the mean number of sexual partners reported by HIV-positive patients.

A cross-sectional survey on the inclusion of tobacco prevention/cessation, nutrition/ diet, and exercise physiology/fitness education in medical school curricula

Chronic diseases are currently the major cause of death and disability worldwide. Addressing the main causes of chronic diseases from a preventive perspective is imperative for half ing a continual increase in premature deaths. Physicians occupy a unique position to assist individuals with chronic disease prevention. Hence, medical school is an opportunity to prepare physicians for preventive interventions with patients at risk for developing chronic diseases. This study asserts that education on chronic disease prevention that targets tobacco cessation/prevention, nutrition/ diet, and exercise physiology/fitness is a key aspect of medical school curricula. However, many US medical schools do not include all 3 components in their curricula. This study investigates the extent to which medical school curricula include the above 3 areas. Two methods were utilized for the study: (1) a cross-sectional survey was given to the associate dean of academic affairs of 129 US medical schools and (2) relevant data were retrieved from the Association of American Medical Colleges. Findings support the notion that medical schools are in need of increased curricula covering tobacco prevention/cessation, nutrition/diet, and exercise physiology/fitness. Results indicate that exercise physiology/fitness was the area receiving the least attention in medical schools. Ultimately, this study's purpose was to provide a basis for determining whether inclusion of these 3 subjects in medical school curricula has any significant effect on training future doctors to meet the needs of growing numbers of individuals with chronic disease.

The impact of motivational interventions for increasing physical activity

ABSTRACT Objective: To assess whether incentives for practicing regular physical activities in fact help raising the frequency of exercising. Methods: Male and female subjects undergoing two to three assessments in the Check-Up Unit of Hospital Israelita Albert Einstein (HIAE) were evaluated by noting any increase in levels of physical activity, improvements in mean metabolic unit numbers, and the sensitization index. The International Physical Activity Questionnaire was applied to assess the sample. Results: There were 1,879 subjects − 1,559 (83%) males and 320 (17%) females – aged 20 to 76 years (mean age = 45.8 years, standard deviation ± 8.8) who underwent a Continued Health Review at the Center for Preventive Medicine of the HIAE, Check-Up Unit, Jardins. Initially, over half of the sample was insufficiently active (sedentary or poorly active); there were more women than men in this group. After the health review, most subjects increased their level of physical activity; this increase was higher among women. Males encouraged three times to exercising showed better results (increased level of physical activity) as compared to males encouraged twice for exercising. The best results in females were found in the group that went through two evaluations. This result is due to the fact that the sample of females comprising the group that received incentives on three occasions was small. This was also the only group that showed no increase in mean metabolic units. The sensitization index assessment in the overall sample was very satisfactory, as the expected results were achieved. Conclusions: These results show that motivational interventions are effective for raising the level of physical activity. We concluded that to encourage the practice of regular physical activity through information programs about its health benefits is very important.

Risk behaviours in HIV-positive men who have sex with men participating in an intervention in a primary care setting

Men who have sex with men receiving HIV care reported their sexual behaviours and their intentions, classified according to the Transtheoretical Model of Change, to modify the following behaviours: (1) condom use by partner type and activity type; (2) reduction of partner number; and (3) disclosure of HIV serostatus to partners. Most participants were white (68.8%) or black (29.5%) and were more likely to report unprotected sex with HIV-positive than with serodiscordant partners for most activities. Whites reported more partners than black patients (mean 4.1 versus 2; P < 0.0001) and black participants reported fewer HIV-negative (P = 0.0084) and -unknown status partners (P = 0.00095) than whites. Cocaine/crack use was associated with more sexual partners (P = 0.001) and more frequent unprotected sex with HIV-negative or -unknown status partners (P = 0.036). Readiness to change risk behaviour varied by partner status and type of sexual activity. Understanding patients' risks and their readiness to change behaviours may help providers to promote sexual health.

Physician-based physical activity counseling for middle-aged and older adults: a randomized trial

Sedentary behavior among older adults increases risk for chronic diseases. Physicians in a primary care setting can play an important role in promoting physical activity adoption among their older patients. The Physically Active for Life (PAL) project was a randomized, controlled trial comparing the efficacy of brief physician-delivered physical activity counseling to usual care on self-reported physical activity levels. The physical activity counseling was based on the Transtheoretical Model of Change and social learning theory. Twenty-four community-based primary care medical practices were recruited into the study; 12 were randomized to the Intervention condition and 12 to the Control condition. Physicians in the Intervention practices received training in the delivery of brief physical activity counseling. Subjects in the Intervention practices (n=181) received brief activity counseling matched to their stage of motivational readiness for physical activity, a patient manual, a follow-up appointment with their physician to discuss activity counseling, and newsletter mailings. Subjects in the Control practices (n=174) received standard care. Measures of motivational readiness for physical activity and the Physical Activity Scale for the Elderly (PASE) were administered to subjects in both conditions at baseline, 6 weeks following their initial appointment, and at 8 months. Results showed that at the 6-week follow-up, subjects in the Intervention condition were more likely to be in more advanced stages of motivational readiness for physical activity than subjects in the Control condition. This effect was not maintained at the 8 month follow-up and the intervention did not produce significant changes in PASE scores. Results suggest that more intensive, sustained interventions may be necessary to promote the adoption of physical activity among sedentary, middle-aged, and older adults in primary care medical practices.

Examining physician counselling to promote the adoption of physical activity

BACKGROUND

While the benefits of physical activity are generally recognized, over half of adult Canadians are not active enough to receive those benefits. Physicians may influence patient activity through counselling; however, research is inconsistent regarding their effectiveness in doing so. Increasing patients' use of self-regulatory skills in managing their activity and additional telephone support are suggested as two means of improving physician counselling. When assessing the effectiveness of physician counselling, it may be important to measure both outcome and treatment adherence. We compared physician-directed activity counselling (modified PACE protocol) with a modified PACE protocol augmented with telephone-based counselling for patient support for both outcome and treatment adherence.

METHODS

Physicians counselled 90 patients using a modified PACE protocol that included self-regulatory skills. Physical activity was assessed by questionnaire at baseline (prior to counselling) and one month later. Participants were divided into two groups: counselling (modified PACE counselling) and enhanced counselling (modified PACE counselling plus telephone support).

RESULTS

The main outcome (mean energy expenditure) and secondary outcomes of treatment adherence (frequency, frequency of moderate activity, and duration) significantly increased over time (p < 0.05). No significant interactions between group and time were found.

INTERPRETATION

Our results support the effectiveness of physician counselling for activity that included the use of self-regulation skills. The effectiveness of telephone support over and above that of physician counselling was not supported. Our results demonstrate that assessing treatment adherence provides a means of discerning whether the counselling intervention was delivered as intended.

A process evaluation of the implementation of a computer-based, health provider-delivered HIV-prevention intervention for HIV-positive men who have sex with men in the primary care setting

There is increasing interest in using healthcare providers to deliver HIV-prevention services to their patients. Unfortunately, lack of counselling skills and time constraints within busy clinics serve as barriers to such efforts. The Providers Advocating for Sexual Health Initiative (PASHIN) study used state-of-the-art computer technology to assess each participant's risk behaviours and to determine the patient's readiness for changing each behaviour. The computer synthesized the participant-entered data, determined the targeted risk behaviour and printed a behavioural theory-based provider advice sheet and a 3-point patient prescription for the targeted risk behaviour. Since the intervention does not require providers to spend time performing a detailed sexual-risk assessment and it does not require providers to have received extensive counselling training, it has the potential to minimize some of the barriers associated with provider-delivered interventions. Thus, the purpose of this process evaluation was to assess how the PASHIN intervention was implemented in the field, including issues such as the fidelity of implementation and health providers' views on and experience with implementing the intervention. Overall, the results demonstrated that the computer-based, provider-delivered intervention was successfully delivered by providers within the context of regularly scheduled treatment sessions with HIV-positive men who have sex with men (MSM) patients. The majority of providers (79.4%) and patients (83.5%) reported that the quality of HIV-prevention services delivered during these sessions was 'good'. The majority of the providers also reported that they had received adequate training, felt more confident in communicating HIV-prevention issues with their patients and provided more HIV-prevention counselling to their patients, due to the project. However, the experience of delivering HIV-prevention counselling during an 18-month period did not appear to change providers' attitudes toward a provider-delivered HIV-prevention intervention nor their belief in the effectiveness of HIV prevention in general. Future studies should focus on how to enhance providers' acceptance and commitment to delivering HIV-prevention counselling to their patients during the clinic visit.

Provider-delivered, theory-based, individualized prevention interventions for HIV positive adults receiving HIV comprehensive care

HIV prevention efforts are often difficult to emphasize in settings delivering comprehensive HIV care due to factors such as time constraints and differing priorities about the use of clinical time. To assist clinicians within dedicated HIV clinics to offer prevention strategies, investigators at two universities in the United States (Johns Hopkins University and the University of Alabama at Birmingham) have developed and implemented similar, audio-computerized-assisted, self-interviewing systems that have been programmed to assess individual patient risk factors and identify based on the patient's self-assessment, the patient's behavioral stage or, readiness for changing, each identified target behavior. Following the assessment, the systems provide printouts of key elements of this information along with individualized, theory-based intervention strategies to the medical provider. This paper will describe our efforts in developing provider-delivered, individualized, stage-based interventions intended to reduce high-risk behaviors among HIV-infected persons.

State of the Art Review: Promoting Physical Activity in Primary Care Settings: A Review of Cognitive and Behavioral Strategies

Despite recognition that physical activity is associated with numerous health benefits, many Americans do not meet current guidelines for physical activity. Primary care providers are in a unique position to influence physical activity, though conflicting evidence exists regarding the effectiveness of primary care—based physical activity promotion. The present article provides a qualitative review of the literature on physical activity promotion within primary care settings, focusing specifically on types of cognitive and behavioral intervention strategies that can be implemented into routine practice by primary care providers. The authors searched MEDLINE and identified 16 studies that met relevant experimental, intervention, and outcome criteria. Intervention types were defined as those involving education, advice, self-monitoring, face-to-face counseling, and telephone follow-up. Most interventions included multiple components. Within the limitations of the review, results suggest that a variety of interventions are effective at increasing physical activity and/or fitness of middle-aged and older adults, among both men and women. More research is needed to determine which interventions are most effective in which doses and combinations, with ethnic minorities and younger adults, and regarding long-term outcomes.

Psychosocial interventions by general practitioners

BACKGROUND

Many patients visit their general practitioner (GP) because of problems that are psychosocial in origin. However, for many of these problems there is no evidence-based treatment available in primary care, and these patients place time-consuming demands on their GP. Therefore, GPs could benefit from tools to help these patients more effectively and efficiently. In this light, it is important to assess whether structured psychosocial interventions might be an appropriate tool for GPs. Previous reviews have shown that psychosocial interventions in primary care seem more effective than usual care. However, these interventions were mostly performed by health professionals other than the GP.

OBJECTIVES

To examine the effectiveness of psychosocial interventions by general practitioners by assessing the clinical outcomes and the methodological quality of selected studies.

SEARCH STRATEGY

The search was conducted using the CCDANCTR-Studies and CCDANCTR-References on 20/10/2005, The Cochrane Library, reference lists of relevant studies for citation tracking and personal communication with experts.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials and controlled patient preference trials addressing the effectiveness of psychosocial interventions by GPs for any problem or disorder. Studies published before November 2005 were eligible for entry.

DATA COLLECTION AND ANALYSIS

Methodological quality was independently assessed by two review authors using the Maastricht-Amsterdam Criteria List. The qualitative and quantitative characteristics of selected trials were independently extracted by two review authors using a standardised data extraction form. Levels of evidence were used to determine the strength of the evidence available. Results from studies that reported similar interventions and outcome measures were meta-analysed.

MAIN RESULTS

Ten studies were included in the review. Selected studies addressed different psychosocial interventions for five distinct disorders or health complaints. There is good evidence that problem-solving treatment by general practitioners is effective for major depression. The evidence concerning the remaining interventions for other health complaints (reattribution or cognitive behavioural group therapy for somatisation, cognitive behavioural therapy for unexplained fatigue, counselling for smoking cessation, behavioural interventions to reduce alcohol reduction) is either limited or conflicting.

AUTHORS' CONCLUSIONS

In general, there is little available evidence on the use of psychosocial interventions by general practitioners. Of the psychosocial interventions reviewed, problem-solving treatment for depression may offer promise, although a stronger evidence-base is required and the effectiveness in routine practice remains to be demonstrated. More research is required to improve the evidence-base on this subject.

Utility of a Web-based intervention for individuals with type 2 diabetes: the impact on physical activity levels and glycemic control

Despite the numerous benefits of physical activity for patients with diabetes, most healthcare providers in busy clinical settings rarely find time to counsel their patients about it. A Web-based program for healthcare providers can be used as an effective counseling tool, when strategies are outlined for specific stages of readiness for physical activity. Seventy-three adults with type 2 diabetes were randomly assigned to Web-based intervention, printed-material intervention, or usual care. After 12 weeks, the effects of the interventions on physical activity, fasting blood sugar, and glycosylated hemoglobin were evaluated. Both Web-based and printed material intervention, compared with usual care, were effective in increasing physical activity (P < .001) and decreasing fasting blood sugar (P<.01) and glycosylated hemoglobin (P < .01). Post hoc analysis for change scores indicated significant differences between Web-based intervention and usual care and between printed material intervention and usual care, but not between web-based and printed material intervention. The findings of this study support the value of Web-based and printed material interventions in healthcare counseling. With increasing Web access, the effectiveness of Web-based programs offered directly to patients needs to be tested.

Examination of print and telephone channels for physical activity promotion: Rationale, design, and baseline data from Project STRIDE

BACKGROUND

Project STRIDE is a 4-year randomized controlled trial comparing two computer-based expert system guided intervention delivery channels (phone vs. print) for physical activity adoption and short-term maintenance among previously sedentary adults.

METHODS

Sedentary adults (n=239) were randomized to one of the following (1) telephone-based, individualized motivationally-tailored feedback; (2) print-based, individualized motivationally-tailored feedback; (3) contact-control delayed treatment group (received intervention after 12 months as control). This paper: (1) outlines the study design, rationale, and participant sample; and (2) describes relationships between baseline variables to better understand their influence on the efficacy of the intervention.

RESULTS

Participants averaged 19.8+/-25.0 min of physical activity/week that was at least of moderate intensity, with no group differences. The average estimated VO(2) at 85% of maximum heart rate was 25.6 ml/kg/min. Body fat was 34.1% for women and 23.2% for men and the BMI of the sample averaged 28.5 kg/m(2).

CONCLUSIONS

Project STRIDE examines non face-to-face approaches for promoting physical activity behavior. It has unique features including a direct comparison of an expert system guided intervention delivered via phone or print. Future analyses will examine the cost-effectiveness of the interventions and this will likely yield important information for policy-makers.

Physical activity counseling in primary care: who has and who should be counseling?

OBJECTIVE

To examine the physical activity (PA) counseling literature in primary care in order to identify which intervention provider has been used to date and their relative effectiveness for increasing PA.

METHOD

MEDLINE and PsycINFO databases were searched for PA intervention studies in primary care settings.

RESULTS

Of the 19 studies, 37% were conducted solely by physicians, 37% by allied health professionals, while 26% were combined-provider interventions. There was a decline in the number of physician-only interventions and a shift towards interventions offered by allied health professionals as adjuncts or alone. Interventions across all provider categories generated some improvements in physical activity behavior, however, it appears that allied health professionals as adjuncts or alone produced the best results in the long-term (>6 months). There was substantial variation in the location and counseling approach employed by allied health professionals.

CONCLUSION

We argue for an interdisciplinary model in which physicians recommend PA and provide referrals to allied health professionals such as physical activity counselors.

PRACTICE IMPLICATIONS

With physical activity counselors' specialized training and greater time available to the patient, they may provide more intensive and effective counseling required for behavior change and maintenance.

Motivating for cancer prevention

Effective habit change usually requires a combination of psycho-educational, behavioural, and social learning strategies. Motivational interview and shared decision making are likely to be the most efficient approaches. Assessing the current motivation can be based on the transtheoretical model of change (TTM) with the goal to move from one behaviour to another healthier one. In a daily busy clinical practice, brief counselling interventions of one to three visits can substantially help patients change problematic behaviours, particularly in the areas of smoking cessation and exercise. The acronym FRAMES has been used to define the elements of an effective brief intervention which helps to trigger the patient motivation to change; giving Feedback based on a thorough assessment; helping the patient take Responsibility for changing; giving clear Advice on what behaviour must change; offering a Menu of options for making the change; expressing Empathy for the ambivalence and difficulty in making changes; enhancing Self-efficacy to foster commitment and confidence. This chapter reviews relevant aspects of clinician-patient communication with regard to cancer prevention, especially smoking cessation and exercise.

Applying the transtheoretical model to exercise: a systematic and comprehensive review of the literature

Three questions guided a literature review of the transtheoretical model (TTM) as applied to exercise to address the evidence for stage-matched interventions, the description of priority populations, and the identification of valid TTM measurement tools. One-hundredand-fifty studies were reviewed. Results indicate preliminary support for the use of stage-matched exercise interventions. Most studies have focused on White, middle-class, female populations, limiting the generalizability of their findings. Valid and reliable measures exist for stage of change, decisional balance, processes of change, self-efficacy, and temptations to not exercise; however, more research is needed to refine these measures. Evidence for the construct validity of the TTM as applied to exercise is mixed. When designing and implementing TTM-based exercise interventions, practitioners and policy makers are encouraged to clearly define the term exercise, choose a valid and reliable staging tool, and employ all TTM constructs and not just stage membership.

Relationship of Internet health information use with patient behavior and self-efficacy: experiences of newly diagnosed cancer patients who contact the National Cancer Institute's Cancer Information Service

This study examines the relationship of Internet health information use with patient behavior and self-efficacy among 498 newly diagnosed cancer patients. Subjects were classified by types of Internet use: direct use (used Internet health information themselves), indirect use (used information accessed by friends or family), and non-use (never accessing Internet information). Subjects were recruited from callers of the National Cancer Institute's (NCI's) Cancer Information Service, Atlantic Region. They were classified by type of Internet use at enrollment and interviewed by telephone after 8 weeks. There were significant relationships among Internet use and key study variables: subject characteristics, patient task behavior, and self-efficacy. Subjects' Internet use changed significantly from enrollment to 8 week follow-up; 19% of nonusers and indirect users moved to a higher level of Internet use. Significant relationships also were found among Internet use and perceived patient-provider relationship, question asking, and treatment compliance. Finally, Internet use was also significantly associated with self-efficacy variables (confidence in actively participating in treatment decisions, asking physicians questions, and sharing feelings of concern). The results of this study show that patients who are newly diagnosed with cancer perceive the Internet as a powerful tool, both for acquiring information and for enhancing confidence to make informed decisions.

Recommendations for and warnings against physical activity given to older people by health care professionals

BACKGROUND

Little is known about how health care professionals advice older people with chronic conditions about physical exercise. This study investigated exercise counseling in the context of health care as perceived by older people, and factors associated with perceived advice.

DESIGN AND METHODS

Participants were 580 non-institutional 73- to 92-year-old people who reported at least one contact with health care during the previous 12 months.

RESULTS

Of all the participants, 23% recalled solely recommendations to exercise, and 9% solely warnings against exercise. Additionally, 34% recalled receiving both recommendations for and warnings against physical activity, and 34% did not recall exercise-related advice at all. Recalling solely recommendations to exercise was associated with having musculoskeletal diseases and impaired mobility. Reporting solely warnings against physical activity was more common among those having heart conditions. Recalling both recommendations for and warnings against exercise was associated with being physically active despite of having heart conditions, musculoskeletal diseases, and impaired mobility. Recalling no exercise-related advice was most common among people who were sedentary and older, had fewer chronic conditions and reported no mobility limitation.

CONCLUSIONS

A substantial proportion of older people recalled negative, no, or contradicting advice about exercise. As warnings against physical activity may outweigh recommendations to exercise, special attention should be paid to the content of advice in order to avoid discouraging older people from being active.

Promoting physical activity in Australian general practices: a randomised trial of health promotion advice versus hypertension management

A randomised controlled trial was conducted to determine if physicians' advice to promote physical activity to patients was more effective if the advice was tailored to the management of hypertension, compared with more general health promotion advice. Participants included inactive 40- to 70-year-old patients visiting the physicians' during study recruitment period. Physicians provided verbal physical activity advice and written materials, both tailored to either general health promotion messages or specifically as a means for treating or managing hypertension. Seventy-five physicians and 98% (767/780) of screened eligible patients participated in the study. Differences between intervention and control groups self-reported physical activity were assessed over 6 months. Follow-up response rates were 92 and 84% at the 2- and 6-month assessments. There were no consistent, significant differences between groups at the 2- or 6-month assessments. Thus, neither intervention strategy resulted in significant changes in patients self-reported physical activity, regardless of the whether the advice was tailored to hypertension management or general health promotion advice.

The impact of a stage-matched intervention to promote exercise behavior in participants with type 2 diabetes

This study was designed to develop and evaluate a stage-matched intervention (SMI) in Korean participants with type 2 Diabetes. The SMI was based on main constructs derived from the Transtheoretical Model match to the individual's stages of readiness for exercise behavior. The SMI was developed according to the results of the content validity tested by an expert group (n = 9). A control group pre- and post-test design was used for evaluating the impact of the SMI: the intervention group (n = 22) participated in the SMI for 3 months, while the control group (n = 23) received usual educational advice. The intervention group, compared to the control group, showed significant improvements in stages of change for exercise behavior (p < 0.001), physical activity levels (p < 0.001), and reductions in FBS (p < 0.05) and HbA(1)c (p < 0.05). This study yielded evidence for the beneficial impact of the SMI in participants with type 2 Diabetes.

How general practitioners promote 'lifestyle' physical activity

We investigated how General Practitioners (GPs) promote lifestyle physical activity (PA) ('accumulate 30 min of at least moderate PA on 5 or more days per week': PA30 x 5) to patients in the different stages of change, using a range of counselling strategies. These strategies included six 'A' factors (Ask, Assess, Advise, Assure, Arrange a follow-up, and Applaud). In a postal questionnaire (68% return rate), 47% of GPs from a single UK health district reported regularly promoting PA30 x 5. A stepwise logistic regression identified three counselling strategies that predicted regularly promoting PA30 x 5: (1) arrange follow-ups for patient pre-contemplators (OR=4.93), (2) patient contemplators passed to GP exercise referral scheme (OR=2.34), and (3) asking relapsers about their PA30 x 5 (OR=2.61). GPs who regularly promote PA30 x 5 base their counselling on patients' pre-existing PA behaviour, using 'effortful', 'stage-matched' approaches. Since these are acceptable to GPs, in-service training may build on using these three factors.

Implementation of a cancer prevention program for working class, multiethnic populations

BACKGROUND

This paper describes the implementation of the Healthy Directions-Health Centers intervention and examines the characteristics of participants associated with completion of intervention activities. Healthy Directions-Health Centers was designed to address social contextual factors relevant to cancer prevention interventions for working class, multi-ethnic populations.

METHODS

Ten community health centers were paired and randomly assigned to intervention or control. Patients who resided in low income, multi-ethnic neighborhoods were approached for participation. This study targeted fruit and vegetable consumption, red meat consumption, multi-vitamin intake, and physical activity. The intervention components consisted of: (1) a brief study endorsement from a clinician; (2) an in-person counseling session with a health advisor; (3) four follow-up telephone counseling sessions; and (4) multiple distributions of tailored materials.

RESULTS

Among the 1,088 intervention group participants, 978 participants (90%) completed at least five out of six intervention activities. Participants who missed clinical appointments were less likely to complete all components of the intervention. Participant characteristics that predicted receipt of clinician endorsement differed from characteristics that predicted completion of health advisor activities. Low acculturation did not present a barrier to delivery of the intervention once the participant was enrolled.

CONCLUSIONS

Collection and reporting on process evaluation results can help explain variations in program implementation.

Stage-based lifestyle interventions in primary care: are they effective?

BACKGROUND

To systematically review the literature concerning the effect of stages-of-change-based interventions in primary care on smoking, physical activity, and dietary behavior.

METHODS

An extensive search (until July 2002) was performed using the following inclusion criteria: (1) (randomized) controlled trial (RCT/CT), (2) intervention initiated in primary care, (3) and intervention aimed at changing smoking, physical activity, or dietary behavior, and stages-of-change-based outcomes, and (4) behavioral outcomes. Methodologic quality was assessed, and conclusions on the effectiveness at short-, medium-, and long-term follow-up were based on a rating system of five levels of evidence. Odds ratios were calculated when methodologically appropriate.

RESULTS

A total of 29 trials were selected for inclusion. Thirteen studies included a physical activity intervention, 14 aimed at smoking cessation, and five included a dietary intervention. Overall methodologic quality was good. No evidence was found for an effect on stages of change and actual levels of physical activity. Based on the strength of the evidence, limited to no evidence was found for an effect on stages of change for smoking and smoking quit rates. Odds ratios for quitting smoking showed a positive trend. Strong evidence was found for an effect on fat intake at short- and long-term follow-up. Limited evidence was found for an effect on stages of change for fat intake at short-term follow-up.

CONCLUSIONS

The scientific evidence for the effect of stages-of-change-based lifestyle interventions in primary care is limited. Limiting aspects in the stages-of-change concept with respect to complex behaviors as physical activity and dietary behavior are discussed.

A randomized pilot test of “moms on the move”: A physical activity intervention for WIC mothers

BACKGROUND

Sedentary mothers are important to reach with physical activity promotion.

PURPOSE

This study pilot tested "Moms on the Move," a Transtheoretical Model (TTM)-derived physical activity (PA) intervention for low-income mothers enrolled in the Women, Infants, and Children (WIC) program.

METHOD

Sedentary mothers (N = 44) were randomized to (a). Moms on the Move (PA intervention) or (b). counseling on self-breast examination (control). Pre- and posttest measurement (baseline and 2 weeks after the 8-week interventions) included (a). stage of PA behavior change, (b). PA behavior, (c). selected TTM constructs, and (d). social support. Pre- and postdifference scores, chi-square, and one-way analyses of variance (ANOVAs) were used.

RESULTS

The experimental group progressed in stage of change more than control, chi2(1, N = 44) = 20.50, p <.001. The experimental group had greater PA behavior: weekly minutes of PA, F(1, 42) = 46.85, p <.001; daily energy expenditure (EE), F(1, 42) = 23.01, p <.001; and weekly moderate PA EE, F(1, 42) = 32.63, p <.001. Experimental subgroup (n = 11) step counts increased pre-post, t(10) = 6.16, p <.001. An ANOVA showed that the experimental group had greater improvements in all TTM constructs and social support, ps <.001.

CONCLUSIONS

WIC mothers are at risk for sedentary living and have not been targeted for PA behavior change using a provider-counseled approach. Although further testing is needed, Moms on the Move appears to be efficacious.

Assessing the health of future physicians: an opportunity for preventive education

INTRODUCTION

Research shows that physicians who model prevention are more likely to encourage preventive behaviors in their patients. Therefore, understanding the health of medical students ought to provide insight into the development of health promotion programs that influence the way these future physicians practice medicine. A university-based General Clinical Research Center (GCRC) provides a venue well suited to the health assessment and education of medical students. This research explores the utility of a GCRC in a program measuring the prevalence of clinical risk factors and related health behaviors in first-year medical students.

METHODS

A 6-year cross-sectional study of first-year medical students measured clinical and behavioral variables associated with metabolic syndrome. Statistical testing was used to determine the prevalence of risk factors and the influence of gender in these variables.

RESULTS

This group of medical students displayed better health indicators than did the general young adult population; however a small proportion of medical students exhibited early risk factors for chronic disease. There were significant gender differences in mean values for clinical risk factors, with males displaying higher cardiovascular risk overall. Males and females demonstrated significant differences in dietary intake and exercise programs.

DISCUSSION

A GCRC can be used to provide a health assessment of medical students. Moreover, some students may benefit from health promotion programs incorporated into medical school curricula. This study provides a foundation for further research on the health of future physicians and the development of health promotion programs for this population. It also begins to explore the use of a GCRC as a teaching resource for medical students.

Eliminating disparities: empowering health promotion within preventive medicine

The estimated 800,000 U.S. deaths in 1990 related to behavioral decisions challenge physicians to better assist behavioral change through expanded health promotion activities. Based on the format guidelines of this special issue, this brief paper first examines the current and optimal roles of health promotion within Preventive Medicine, including five physician roles for improving modifiable public health-risk behavior burdens: (1) preventive services clinician, (2) health promotion researcher, (3) educator-communicator, (4) systems manager, and (5) health promotion advocate. After presenting a new vision statement, this paper proceeds to discuss the opportunities and barriers, including system, clinician-office, and patient factors, to attaining this new vision of empowering health promotion within Preventive Medicine. Finally, all physicians are invited to engage in a threefold strategic plan for change through at least one of five action items: (1) health promotion advocacy, (2) health promotion research, (3) public communication, (4) protocol dissemination and implementation, and (5) Preventive Medicine training.

Population-based randomized controlled trial of a stage-targeted physical activity intervention

BACKGROUND

Intervention trials with self-selected participants have shown that mailed stage-targeted print materials can increase participation in physical activity in the short term. We examined the effects of a mailed stage-targeted print intervention designed to promote physical activity, in a random sample of adults living in a regional city.

METHOD

Participants (n = 462, 40-60 years of age) were randomly allocated to an intervention (n = 227) or control group (n = 235). Measures included validated 2-week physical activity recall and stage of motivational readiness for physical activity. The intervention consisted of a single mailing of a letter and full-color stage-targeted booklets (specific to precontemplation, contemplation, preparation, and action/maintenance) 1 week postbaseline. Follow-up interviews were conducted at 2 and 6 months postbaseline.

RESULTS

After 2 months, participants in the intervention group were significantly more likely to meet the current American College of Sports Medicine/Centers for Disease Control and Prevention recommendation for sufficient physical activity than those in the control group (adjusted odds ratio [OR] = 2.40; 95% confidence interval [CI] = 1.44-3.99). After 6 months, intervention participants who reported receiving and reading the intervention materials were significantly more likely to be meeting the sufficient physical activity criterion compared with the control group (adjusted OR = 2.03; 95% CI = 1.16-3.56).

CONCLUSIONS

The stage-targeted print intervention was effective in promoting short-term increases in physical activity and was most effective for participants who recognized and used the materials. This low-cost, generalizable intervention has demonstrated potential as a practical population-based physical activity promotion strategy. Further research is required before widespread dissemination would be justified, as additional strategies may be required to ensure sustained change.

Exercise counselling by family physicians in Canada

BACKGROUND

Exercise counselling is not frequently conducted by family physicians in several countries. Little is known about the exercise counselling practices of family physicians in Canada. The objective of this study was to assess physician confidence, current versus desired practice, and barriers related to the counselling of exercise by family physicians in Canada.

METHODS

The study was a cross-sectional survey that included a random selection of family physicians in six provinces. A total of 330 family physicians completed the questionnaire, resulting in a response rate of 61.1%. A family physician was defined as a physician who practices family medicine at least 75% of their practice time.

RESULTS

A total of 58.2% believed only 0-25% of their patients would respond to their counselling and 42.4% felt "moderately knowledgeable" to exercise counsel. Only 11.8% counselled 76-100% of their patients about exercise, but 43.3% thought they should be counselling 76-100% of their patients. Barriers to exercise counselling that rated most important included lack of time (65.7%) and lack of exercise education in medical school (64.8%).

CONCLUSIONS

Family physicians indicated their current level of exercise counselling is suboptimal and confidence levels in exercise counselling were not high. Future educational opportunities for physicians may assist in improving exercise counselling.

Application of the Transtheoretical Model of behavior change to the physical activity behavior of WIC mothers

This descriptive-correlational study examined the Transtheoretical Model (TTM) of behavior change in relationship to the physical activity behavior of mothers receiving assistance from the Women, Infants, and Children program. A purposive sample (N = 30) of six women at each of the five stages of readiness for behavior change was used. Relationships between stage of behavior change (measured using the Stage of Exercise Adoption tool) and other TTM constructs were examined. The constructs and corresponding instruments included physical activity behavior (Seven-Day Physical Activity Recall), pros, cons, decisional balance (Exercise Benefits/Barriers Scale and two open-ended questions), self-efficacy (Self-efficacy for Exercise scale), and processes of behavior change (Processes of Exercise Adoption tool and the Social Support for Exercise scale). Significant relationships were found between stage of behavior change and two physical activity energy expenditure indices (rs = 0.71-0.73, p < 0.01), daily minutes of moderate to very hard physical activity (rs = 0.81, p < 0.01), pros (rs = 0.56, p < 0.01), cons (rs = -0.52, p < 0.05), decisional balance (rs = 0.56, p < 0.01), and self-efficacy (rs = 0.56, p < 0.01). Use of the 10 processes of change differed by stage of change. Pros to physical activity included a sense of accomplishment, increased strength, stress relief, and getting in shape after pregnancy. Cons included fatigue, childcare, and cold weather. Results support the TTM as relevant to WIC mothers and suggest strategies to increase physical activity in this population.