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

Bodenheimer²⁸ has argued for a redesign of primary care systems to more effectively address chronic conditions rather than acute care needs. Several health care systems have successfully implemented the pillars of such a redesign imperative, and they have shown convincingly the promise of addressing competing priorities, physician competence and confidence, motivation, and durability in improving patient self-management.²⁸

At the level of the clinician-patient relationship, data suggest that patient physical activity can be increased (at least in the short term) by counseling that:

• is brief (5 minutes or less)^17-20,23
• is focused/goal-oriented^17-23
• is molded to the patient’s specific health needs^17-23
• is delivered over multiple contacts (whether it be office visits, telephone, or group sessions)^17-23
• contains a written plan to achieve goals.^17-23

We do not know what “dose-response” relationship exists for primary care clinician communication with patients over the long term, and what effect repeated counseling would have on long-term sustainability of physical activity levels. This is even less clear for underserved groups. It is also unknown to what extent collaborative links with community programs might increase physical activity when added to primary care–based counseling. Future research should evaluate the optimal “dose-response” to the interventions, the effect of repeated visits and continuity of care, and the effect of community-based referrals for physical activity programs for underserved populations in primary care.

Limitations of this review

Because our inclusion criteria were strict, we omitted potentially meaningful studies that were less directly relevant to our aims. For example, there has been substantial creative community-based work with underserved populations in the US to promote physical activity, and many innovations have been designed by researchers outside the US. Results from these programs and trials should be incorporated into primary care settings working with underserved populations.

Another limitation is that our definition of “underserved” is not the only possible definition. The most marginalized underserved groups with the least access to the health care system (such as the uninsured or homeless) were more likely to be omitted from our results, because we wanted to examine physical activity programs among patients in primary care settings.

Finally, this review did not address the need to understand the connection between sustained improvements in physical activity and patient-oriented health outcomes for underserved populations.

Conclusion

Information on exercise counseling interventions in primary care for the underserved is limited: these groups have not been included in the majority of clinical trials of physical activity thus far. Physical activity interventions need to be replicated in underserved populations before we can assume their results are generalizable. Though characteristics of existing studies show promise, future research on physical activity in underserved populations should assess the effect of practice-based systems on reducing barriers and promoting physical activity, the dose-response effect of clinician counseling on physical activity outcomes, and the effect of the physician-patient relationship and continuity of care on physical activity outcomes.

Funding

This study was supported by grant 1R25CA102618 from the National Cancer Institute.

Correspondence
Jennifer K. Carroll, MD, MPH, University of Rochester School of Medicine, Family Medicine Research Programs, 1381 South Avenue, Rochester, NY 14620; jennifer_carroll@urmc.rochester.edu