How to make exercise counseling more effective: Lessons from rural America

Prevention Research Center and Department of Community Health, Saint Louis University School of Public Health, St. Louis, MO USA.
The Journal of family practice (Impact Factor: 0.89). 06/2008; 57(6):394-402.
Source: PubMed


Exercise counseling by primary care physicians has been shown to improve physical activity in patients. However, the prevalence and effectiveness of physician counseling is unknown in rural populations that are at increased risk for chronic diseases.
Using a population-based telephone survey at baseline and again at 1-year follow-up, we assessed physical activity behavior among 1141 adults (75% female, 95% white) living within 12 rural communities of Missouri, Tennessee, and Arkansas. We tested the association between physician counseling and patients meeting current physical activity recommendations using logistic regression analysis controlling for demographic variables.
Participants who saw a doctor for regular care were 54% more likely to be physically active (adjusted odds ratio [aOR]=1.54; 95% confidence interval [CI], 1.04-2.28). Overweight adults (body mass index [BMI]=25-29.9 kg/m2) who had been advised by their physician to exercise more were nearly 5 times more likely to meet physical activity recommendations if their doctor helped develop an exercise plan (aOR=4.99; 95% CI, 1.69-14.73). Overweight individuals who received additional follow-up with the exercise plan from their doctor had a 51/2-fold increase in likelihood of meeting physical activity recommendations (P<.05). In the overall sample, patients were significantly more likely to initiate (P=.01) and maintain (P=.002) physical activity when the physician prescribed and followed up on an exercise plan.
This longitudinal study provides evidence that exercise counseling is most effective when the physician presents the counseling as a plan or prescription and when he or she follows up with the patient on it.

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    • "When advice is given it is more effective if the doctor presents his recommendations about physical activity as a detailed prescription. The effect increases further if the doctor follows up the prescription [16]. Despite studies showing that PAP is an effective complement to or substitute for medication, it seems as if PAP is not used to its full potential [17,18]. "
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    ABSTRACT: Physical activity on prescription (PAP) is a successful intervention for increasing physical activity among patients with a sedentary lifestyle. The method seems to be sparsely used by general practitioners (GPs) and there is limited information a bout GPs' attitudes to counselling using PAP as a tool. The aim of the study was to explore and understand the meaning of prescribing physical activity from the general practitioner's perspective. Three focus group interviews were conducted with a purposive sample of 15 Swedish GPs in the south of Sweden. Participants were invited to talk about their experience of using PAP. The interviews were transcribed verbatim, analysed using qualitative content analysis. The analysis resulted in four categories: The tradition makes it hard to change attitude, Shared responsibility is necessary, PAP has low status and is regarded with distrust and Lack of procedures and clear guidelines. Traditionally GPs talk with patients about the importance of an increased level of physical activity but they do not prescribe physical activity as a treatment. Physician's education focuses on the use of pharmaceuticals. The responsibility for patients' physical activity level is shared with other health professionals, the patient and society. The GPs express reservations about prescribing physical activity. A heavy workload is a source of frustration. PAP is regarded with distrust and considered to be a task of less value and status. Using a prescription to emphasize an increased level is considered to be redundant and the GPs think it should be administered by someone else in the health care system. Scepticism about the result of the method was also expressed. There is uncertainty about using PAP as a treatment since physicians lack education in non-pharmaceutical methods. The GPs do not regard the written referral as a prioritized task and rather refer to other professionals in the health care system to prescribe PAP. GPs pointed out a need to create routines and arrangements for the method to gain credibility and become everyday practice among GPs.
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    • "In a survey of 2470 rural adults, 90% of respondents indicated they had regular visits with a physician and 34% reported receiving physician's advice to exercise. Of those receiving advice to exercise, 46% reported a follow-up conversation regarding the physician's exercise recommendations (Weidinger et al., 2008). In a sample of 359 NPs, approximately 50% reported counseling appropriate patients on exercise about three-fourths of the time and one-third of the NPs indicated they tailored exercise counseling strategies specific to rural patients (Tompkins, Belza, & Brown, 2009). "
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    ABSTRACT: To identify key behavioral factors that contribute to physical activity and weight management in overweight, rural women and determine the degree to which social support, stage of behavior change, and self-efficacy for physical activity and depressive symptoms are linked to physical activity, body weight, and body mass index (BMI). Twenty-five overweight or obese rural women completed self-report scales and height and weight measurements; BMI was calculated. Self-report scales included the International Physical Activity Questionnaire (physical activity level), Social Support for Exercise and Social Support Questionnaire (social support), Stage of Exercise Adoption (stage of behavior change), Self-efficacy for Exercise (self-efficacy), and the Patient Health Questionnaire (depressive symptoms). Higher levels of physical activity were associated with greater self-efficacy and the self-esteem domain of social support. Rural women reported more depressive symptoms over the year. Women did not significantly increase physical activity and gained weight during the 1-year study. Rural women have limited resources available to increase physical activity to facilitate weight loss. Routine screening and treatment for depression in rural women may need to be initiated concurrently with interventions to promote health behavior changes.
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    • "A second advantage is that the clinical interface gives clinical providers ongoing feedback and monitoring regarding the progress of patients' walking programs. This second strength is further enhanced by the capability of patients and providers to email each other as needed so that the intervention is not disconnected from clinical practice after referral [41,42]. This is consistent with the PCMH model of care in that the primary health care team remains informed about all aspects of care. "
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    ABSTRACT: Regular participation in physical activity can prevent many chronic health conditions. Computerized self-management programs are effective clinical tools to support patient participation in physical activity. This pilot study sought to develop and evaluate an online interface for primary care providers to refer patients to an Internet-mediated walking program called Stepping Up to Health (SUH) and to monitor participant progress in the program. In Phase I of the study, we recruited six pairs of physicians and medical assistants from two family practice clinics to assist with the design of a clinical interface. During Phase II, providers used the developed interface to refer patients to a six-week pilot intervention. Provider perspectives were assessed regarding the feasibility of integrating the program into routine care. Assessment tools included quantitative and qualitative data gathered from semi-structured interviews, surveys, and online usage logs. In Phase I, 13 providers used SUH and participated in two interviews. Providers emphasized the need for alerts flagging patients who were not doing well and the ability to review participant progress. Additionally, providers asked for summary views of data across all enrolled clinic patients as well as advertising materials for intervention recruitment. In response to this input, an interface was developed containing three pages: 1) a recruitment page, 2) a summary page, and 3) a detailed patient page. In Phase II, providers used the interface to refer 139 patients to SUH and 37 (27%) enrolled in the intervention. Providers rarely used the interface to monitor enrolled patients. Barriers to regular use of the intervention included lack of integration with the medical record system, competing priorities, patient disinterest, and physician unease with exercise referrals. Intention-to-treat analyses showed that patients increased walking by an average of 1493 steps/day from pre- to post-intervention (t = (36) = 4.13, p < 0.01). Providers successfully referred patients using the SUH provider interface, but were less willing to monitor patient compliance in the program. Patients who completed the program significantly increased their step counts. Future research is needed to test the effectiveness of integrating SUH with clinical information systems over a longer evaluation period.
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