Original Research

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

Author and Disclosure Information

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



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

Strength of recommendation (SOR)

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

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

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

Primary care interventions are linked to a change in habits

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

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

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

Clinical trials within7,8 and outside the US9-11 support the potential value of physical activity counseling in primary care. In these studies, as little as 3 to 5 minutes of patient-clinician communication about physical activity was linked to short-term improvement in patients’ exercise habits. As few as 2 or 3 office visits over 6 months were associated with increases in patients’ physical activity levels up to 1 year later. Other features that contributed to their success included having a brief (<3 minutes) counseling component for clinicians, supplementing the counseling with a written exercise prescription, having follow-up contact, and tailoring the counseling to patients’ needs and concerns.

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

Few studies have focused on the underserved

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

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

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


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