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

Several studies designed their interventions to make the clinician counseling brief,^17-20,23 in order to enhance feasibility for busy primary care settings. Three studies^16,21,22 described strategies they used for tailoring the intervention to a specific culture, or for addressing issues of literacy for the written materials. Two studies^16,22 reported that their study staffs were ethnically or culturally representative of the targeted population.

The difficulty of maintaining adherence to physical activity

Three studies^18,19,21 reported having difficulty with attrition among their minority participants; they did not, however, include information specific to minorities in their physical activity outcomes. Studies with highest retention rates (>80%) tended to specifically address barriers to participation, including cultural issues, or they used a “lead-in” period.^16,20,21,23

The studies with the best adherence and retention among black and Hispanic participants, and those participants with low educational attainment,^16,21 used baseline qualitative data regarding management of health behaviors when they designed their interventions. For example, 1 study¹⁶ mentioned cultural adaptations derived from prior qualitative work—such as using program materials that extensively depicted African American individuals, families, and community settings—and using language in the intervention reflecting social values and situations relevant to African Americans.

How exercise data were reported

Six of the 8 (75%) studies^{16,17,19,20,22,23} reported some improvement in short-term physical activity outcomes (TABLE 2, available at www.jfponline.com); however, there was considerable heterogeneity in how these studies measured physical activity outcomes. All 8 incorporated a self-report measure of physical activity, such as the Patient-centered Assessment and Counseling for Exercise (PACE),^17-19 Paffenbarger Physical Activity Questionnaire (PPAQ),¹⁷ 7-day Physical Activity Recall (PAR),^17,20,21,23 and other self-report recall measures to assess physical activity. (A RESOURCE LIST of these instruments is available at www.jfponline.com.) Two studies also measured “states of change,”^17,20 but these states were not consistently defined.

Three studies^17,20,23 included objective measures of physical activity, such as accelerometers; in these studies, there was not substantial variance in physical activity outcomes between the objective and subjective measures.

Discussion

More study needed in the underserved

This review reflects in part the difficult task of designing and implementing realistic interventions for the underserved in primary care. However, interventions must be replicated in these populations before we can necessarily assume that findings from other trials are generalizable, due to issues of access, financial resources, health literacy, beliefs, cultural differences, self-efficacy, and other logistic barriers to traditional care that disproportionately affect underserved groups.

Integrate known personal, social, and environmental factors

Several studies^24-26 have explored the social, demographic, and environmental factors associated with physical activity in minority populations. These studies shed light on the reasons why clinical trials that focus on white, affluent, educated populations might not be generalizable to underserved groups.

To be maximally effective, any interventions for promoting physical activity in the underserved need to find ways to address any cultural or financial barriers, and incorporate factors associated with success. For example, among African American and Hispanic women, having lower “social role strain,” higher attendance at religious services, and a greater feeling that one’s neighborhood was safe were all associated with increased likelihood of exercise.^24-26 Such studies suggest that differences in beliefs, resources, self-efficacy, prior experience, and competing life demands can all contribute to promoting physical activity in some underserved groups. Practically, such findings encourage clinicians to work with patients to help them identify sources of social support and positive influences on their health, and help them articulate internal strengths and personal attributes to succeed in behavioral change.

Despite the variations in training or means of communication in the studies we identified, 2 studies used interventions that were successful at explicitly anticipated and addressed barriers to physical activity.^16,21 These 2 studies also had interventionists who represented the communities of interest, and they used cultural adaptations to promote exercise where appropriate. Thus, limited data suggest that some primary care–based programs improve physical activity in underserved patients, but the effects of communication from the primary care clinician on physical activity is lacking, consistent with other work in the field.^12,27

Promising strategies include office prompts, brief counseling

Primary care clinicians face many time pressures, fiscal constraints, administrative burdens, and competing priorities; these make addressing health promotion behaviors such as physical activity quite difficult. These issues are magnified for clinicians practicing in medically underserved areas. Despite these many challenges, promising opportunities do exist.

On a systems level, practice-based systems to manage chronic diseases have been successfully developed and implemented in the primary care setting; such systems can be tested to promote physical activity, as well. These practice-based approaches include patient registry data, office prompts, and other electronic systems to promote clinician counseling. For example, studies in this review using computer-based programs in primary care offices were feasible and effective.^18,19,21