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

Methods

Looking for studies in underserved populations

We conducted a systematic review of the literature involving clinical trials in the US, looking for trials where counseling interventions are initiated by primary care clinicians, and that assessed behavioral change related to physical activity.

Inclusion criteria

TABLE 1 shows the inclusion criteria and search terms for the literature review. We searched Ovid, Medline, CINAHL, PsycINFO, PubMed, Cochrane, and HealthSTAR for studies published between 1966 and 2005. We also searched bibliographies of retrieved articles, and contacted experts in the field in an effort to obtain other relevant data.

The principal investigator (JKC) reviewed titles and abstracts of all potentially relevant articles to determine whether they met eligibility criteria. Studies that met the criteria were retrieved and abstracted.

Using these predefined criteria, data were extracted from each eligible article. Studies were also rated according to the Strength of Recommendation Taxonomy (SORT), because of its emphasis on patient-oriented outcomes and the quality, quantity, and consistency of evidence.¹⁵

TABLE 1
Inclusion criteria and search terms

Results

6 of 8 studies report increases in physical activity

We reviewed a total of 253 titles and abstracts. Eight studies^16-23 met our inclusion criteria. We were not able to locate any clinical trials that both 1) examined the effect of primary care clinician counseling on physical activity outcomes, and 2) had a study population focused on an underserved group. TABLE 2 (available at www.jfponline.com) shows the characteristics of these 8 studies.

Although we sought trials that defined “primary care clinician” as a professional—such as MD, nurse practitioner (NP), or physician assistant (PA)—who provides longitudinal primary health care, several of these studies considered dieticians, exercise physiologists, or health care workers as primary care clinicians.

Only 1 study²⁰ examined physical activity counseling with an intervention that incorporated a follow-up visit by the primary care clinician, and looked at the long-term effect on physical activity as an outcome. Thus, the degree to which the clinician’s counseling influenced the physical activity outcome in these studies is unclear.

Identifying underserved groups

Information on race or ethnicity (which tended to be reported as a single variable), level of education, and income of participants was reported in the demographic data of all studies’ results, but relationships between these variables and physical activity outcomes were not consistently reported. One study²³ stratified participants by race/ethnicity and health center; 2 studies^16,21 reported analyses and findings for participants according to ethnicity, income, and educational level, as that was their focus.

Overall, however, it is not clear to what extent the interventions succeeded for various underserved groups, even if they were included as participants.

Study designs and the nature of exercise interventions

Seven^16,18-23 of these studies (88%) were randomized controlled trials; the unit of randomization and control group varied. Trials were conducted at 1 or multiple (up to 11) primary care sites. Use of more than 1 method to recruit participants—such as mailings, use of office staff to promote/recruit, advertising, and community announcements—tended to be most effective.

Intervention types included phone and mail interventions,^17-23 computer-based interventions,^18,19,21 visits from a community health worker,^22,23 group classes,^16,22,23 directly supervised physical activity sessions,^16,22,23 clinician counseling,^16-23 and prescription protocols (eg, written, guided action plans).^17-23 Those delivering the intervention varied, and included primary care physicians,^17-23 nurse practitioners or physician assistants,^17-19,23,23 nutritionists,¹⁶ exercise physiologists,¹⁶ community health educators,^20,22,23 and other study personnel.^19,21 Specific elements of interventions that were likely to contribute to patients’ success included addressing financial or environmental/safety issues for exercise,¹⁶ use of trained office staff to provide exercise counseling,^18-20,23 and offering flexibility in choice by tailoring the goals and plans to the patients’ needs and interests.^17-23

The “dose” of clinician counseling varied from very brief (1 to 3 minutes of direct contact on 1 occasion) to more extended (>5 minutes of direct counseling over repeated intervals). Duration of follow-up for the 8 studies ranged from 4 months to 2 years.