Mediators of change in physical activity following an intervention in primary care: PACE

The impact of exercise consultation on activity levels and metabolic markers in obese adolescents: a pilot study

Objective. To assess the impact of exercise consultation on physical activity (PA) levels, anthropometric measures, and metabolic markers in obese adolescents. Methods. Obese adolescents (14-18 years) were randomized to either an exercise consultation (intervention group) or to review "Canada's Physical Activity Guide for Youth" (control group). Outcomes, including accelerometry, anthropometrics, blood pressure, stage of exercise behavior change, fasting glucose, insulin, and lipids, were measured at baseline and 3 months later. Results. Thirty adolescents (mean BMI = 36.1 kg/m(2); SD = 6.9) completed the study. At follow-up, the intervention group had significantly greater PA compared with controls (P < .05). Similarly, the intervention group weighed an average 2.6 kg less than the control group (P < .05), with a mean BMI z-score of 2.15 compared to 2.21 for controls (P = .054). No other differences were noted. Conclusion. Exercise consultation may be a simple approach to increase PA levels, reduce weight, and lower BMI in obese adolescents.

Psychosocial mediators of a faith-based physical activity intervention: implications and lessons learned from null findings

Mediation analyses in faith-based physical activity (PA) interventions targeting African-American adults are lacking. The purpose of this study was to examine the psychosocial mediators of a faith-based PA intervention with African-American adults. Churches were randomly assigned to receive immediate or delayed (1-year later) training in PA program implementation. A subsample of participants from randomly selected churches took part in telephone surveys at baseline and at 1 year. The primary outcome was percentage of participants meeting PA recommendations. MacKinnon's product of coefficients was used to test for mediation. Participants (n = 418) from 20 churches completed the baseline and 1-year follow-up surveys. There were no statistically significant changes in PA behavior at 1 year. The intervention had a marginally significant effect on increasing the amount of instrumental church support received by church members. However, none of the psychosocial variables tested were found to be significant mediators of the intervention. Mediation analyses provided insight into potential reasons as to why the Health-e-AME intervention did not change PA. The intervention did not successfully change the targeted mediators hypothesized to change PA. Potential reasons for these shortcomings as well as issues to address in future faith-based studies are discussed.

Mediators and Readiness to Exercise in Patients at Risk of Symptomatic Peripheral Arterial Disease

To inform future walking interventions, we sought to identify exercise mediators that are associated with readiness to exercise in persons with either asymptomatic peripheral arterial disease (PAD) or disease risk factors. We enrolled participants excluded from a larger behavioral intervention trial for persons with diabetes mellitus and PAD. Participants completed surveys assessing exercise mediators and stage of readiness to exercise (precontemplation, contemplation, or action). Data were analyzed using nonparametric tests. Participants in the stage of action substituted physical activity as an alternative, rewarded themselves, and committed themselves more than other participants (P < .01). Action participants perceived more benefits to exercise than precontemplation participants (P < .05). Contemplation and action participants had higher outcome expectations for exercise, and action participants received more enjoyment from physical activity than precontemplation participants (P < .05 and P = .05, respectively). Identifying these mediators is important for future exercise interventions and treatments.

The effect of tailored e-mails in the workplace. Part II. Increasing overall physical activity

The purpose of this study was to evaluate the impact tailored e-mail messages, based on participants' identified needs, have on intentional physical activity. A quasi-experimental design (two groups, repeated measures) in a population of manufacturing workers (73 employees from two distribution plants of a multi-national manufacturer) was used. Significant differences were found between contemplation-staged participants in the intervention and the comparison groups. In the intervention group, 53.3% of the workers moved forward, as opposed to 19.2% in the comparison group (medium effect size = 0.353). Although both the intervention group and the comparison group increased their number of steps, the comparison group's improvement was most likely attributed to a Hawthorne effect. These results are highly promising given the small sample size and limited "dose". The intervention is one most industries could feasibly implement. Such efforts have the potential to significantly impact public health.

Heart Healthy and Ethnically Relevant (HHER) Lifestyle trial for improving diet and physical activity in underserved African American women

BACKGROUND

African American women are at increased risk for CVD morbidity and mortality relative to white women. Physical inactivity and poor dietary habits are modifiable health behaviors shown to reduce CVD risk. Community health centers have the potential to reach large numbers of African Americans to modify their risk for CVD, yet few lifestyle counseling interventions have been conducted in this setting.

METHODS

The HHER Lifestyle trial is a randomized controlled trial to compare the effects of a standard care intervention (provider counseling, nurse goal setting, and educational materials) to a comprehensive intervention (standard care intervention plus 12 months of telephone counseling and tailored print materials) on changes in physical activity and dietary fat consumption in financially disadvantaged African American women at 6 and 12 months. Secondary outcomes are body mass index, central adiposity, and total cholesterol. Potential mediators of outcome are self-efficacy for overcoming barriers, social support, and decisional balance.

RESULTS

African American women (N=266; 130 standard care, 136 comprehensive intervention) 35 years and older from nine clinics within two community health centers were enrolled. Most participants were overweight or obese with existing chronic health conditions.

CONCLUSION

The HHER Lifestyle trial is unique in that it targets financially disadvantaged African American women from community health centers, incorporates a standard care intervention into a routine clinical appointment, and includes a comprehensive process evaluation. The design will permit further research examining the added effect of regular telephone counseling and tailored print materials to a primary care provider and nurse intervention.

The Effect of Tailored E-mails in the Workplace

The purpose of this study was to evaluate the impact tailored e-mail messages, based on participants' identified needs, have on intentional physical activity. A quasi-experimental design (two groups, repeated measures) in a population of manufacturing workers (73 employees from two distribution plants of a multi-national manufacturer) was used. Significant differences were found between contemplation-staged participants in the intervention and the comparison groups. In the intervention group, 53.3% of the workers moved forward, as opposed to 19.2% in the comparison group (medium effect size = 0.353). Although both the intervention group and the comparison group increased their number of steps, the comparison group's improvement was most likely attributed to a Hawthorne effect. These results are highly promising given the small sample size and limited “dose.” The intervention is one most industries could feasibly implement. Such efforts have the potential to significantly impact public health.

What is the best way to change self-efficacy to promote lifestyle and recreational physical activity? A systematic review with meta-analysis

PURPOSE

Increasing self-efficacy is an effective method to increase physical activity. Despite this, the evidence concerning the most effective techniques to increase self-efficacy in physical activity interventions has not been systematically reviewed. The aim of the present research is to systematically gather, and meta-analyse, intervention studies which aimed to increase self-efficacy for physical activity; to estimate the association between intervention techniques used, and change in self-efficacy achieved.

METHODS

A systematic database search was conducted for papers reporting lifestyle or recreational physical activity interventions. Published intervention studies explicitly targeting self-efficacy in order to change physical activity behaviour in 'healthy' adults were eligible for inclusion.

RESULTS

The search strategy identified 27 unique physical activity intervention studies, with a total of 5,501 participants. A significant, yet small, relationship between the interventions and changes in self-efficacy was found (mean d=0.16, p<.001). Owing to significant heterogeneity, moderator analyses were conducted, examining the association of changes in self-efficacy with whether or not specific intervention techniques were used. Interventions that included feedback on past or others' performance produced the highest levels of self-efficacy found in this review. Vicarious experience was also associated with higher levels of self-efficacy. Persuasion, graded mastery, and barrier identification were associated with lower levels of self-efficacy.

CONCLUSIONS

This meta-analysis forms an evidence base for which psychological techniques are most effective in increasing self-efficacy for physical activity. The results are presented in terms of recommendations for those developing interventions and directions for future research.

Integrating screening and interventions for unhealthy behaviors into primary care practices

BACKGROUND

Four unhealthy behaviors (tobacco use, unhealthy diet, physical inactivity, and risky alcohol use) contribute to almost 37% of deaths in the U.S. However, routine screening and interventions targeting these behaviors are not consistently provided in primary care practices.

METHODS

This was an implementation study conducted between October 2005 and May 2007 involving nine practices in three geographic clusters. Each cluster of practices received a multicomponent intervention sequentially addressing the four behaviors in three 6-month cycles (unhealthy diet and physical inactivity were combined). The intervention included baseline and monthly audits with feedback; five training modules (addressing each behavior plus stages of change [motivational interviewing]); practice facilitation; and bimonthly quality-circle meetings. Nurses, medical assistants, or both were taught to do screening and very brief interventions such as referrals and handouts. The clinicians were taught to do brief interventions. Outcomes included practice-level rates of adoption, implementation, and maintenance.

RESULTS

Adoption: Of 30 clinicians invited, nine agreed to participate (30%).

IMPLEMENTATION

Average screening and brief-intervention rates increased 25 and 10.8 percentage points, respectively, for all behaviors. However, the addition of more than two behaviors was generally unsuccessful. Maintenance: Screening increases were maintained across three of the behaviors for up to 12 months. For both unhealthy diet and risky alcohol use, screening rates continued to increase throughout the study period, even during the periods when the practices focused on the other behaviors. The rate of combined interventions returned to baseline for all behaviors 6 and 12 months after the intervention period.

CONCLUSIONS

It appears that the translational strategy resulted in increased screening and interventions. There were limits to the number of interventions that could be added within the time limits of the project. Inflexible electronic medical records, staff turnover, and clinicians' unwillingness to allow greater nurse or medical-assistant involvement in care were common challenges.

Importance of enjoyment when promoting physical exercise

The purpose of this study was to investigate the importance of enjoyment of exercise in a health care-based intervention aimed at promoting physical exercise in primary health care patients. In a controlled study design, the intervention group was offered a wide range of group exercises over 3 months, followed by support in designing their own exercise program. The control group received usual care. Enjoyment of exercise and exercise level were measured. Associations between enjoyment and exercise level were analyzed using Spearman's rank correlation coefficients. Changes in enjoyment between and within study groups were analyzed by the independent and paired t-test. Associations were found between enjoyment and exercise level (r=0.36, P<0.01), as well as between changes in enjoyment and changes in exercise level (r=0.34, P<0.01). At the 12-month follow-up, enjoyment of exercise was 25% higher in the intervention group than in the control group (P<0.01). In this group of primary health care patients, enjoyment of exercise was associated with exercise level. Enjoyment of exercise seems to be a mediator of exercise level. Furthermore, health care-based interventions seem to be able to affect enjoyment of exercise. Enjoyment of exercise may be important for the long-term effectiveness, of health care-based interventions.

Physical Activity Behavior Change Interventions Based on the Transtheoretical Model: A Systematic Review

This review critically examines Transtheoretical Model (TTM)—based interventions for physical activity (PA) behavior change. It has been suggested that the TTM may not be the most appropriate theoretical model for applications to PA behavior change. However, previous reviews have paid little or no attention to how accurately each intervention represents the TTM. Findings comprise two sections: sample characteristics of each intervention reviewed and a summary outlining the use of the TTM to develop the interventions. Results reveal numerous inconsistencies regarding the development and implementation/application of TTM-based interventions. Specifically, the majority of interventions reported to be based on the TTM fail to accurately represent all dimensions of the model. Therefore, until interventions are developed to accurately represent the TTM, the efficacy of these approaches and the appropriateness of the underpinning theoretical model cannot be determined.

Using self-efficacy theory to develop interventions that help older people overcome psychological barriers to physical activity: a discussion paper

BACKGROUND

Only a fifth of older people undertake a level of physical activity sufficient to lead to health benefit. Misconceptions about the ageing process and beliefs about the costs and benefits of exercise in late life may result in unnecessary self-imposed activity restriction. Thus, adhering to a physical activity can be difficult particularly when the benefits of exercise are often not immediate. Many of the barriers to engaging in physical activity among older people are attitudinal. It is therefore important to take account of the non-physical aspects of physical activity intervention programmes, such as increasing confidence. Self-efficacy is a widely applied theory used to understand health behaviour and facilitate behavioural modification, such as the increase of physical activity.

AIM

This paper aims to examine the ways in which self-efficacy theory might be used in intervention programmes designed to overcome psychological barriers for increasing physical activity among older people.

CONCLUSION

A number of studies have demonstrated that exercise self-efficacy is strongly associated with the amount of physical activity undertaken. Evidence from some trials supports the view that incorporating the theory of self-efficacy into the design of a physical activity intervention is beneficial. Physical activity interventions aimed at improving the self perception of exercise self-efficacy can have positive effects on confidence and the ability to initiate and maintain physical activity behaviour. There are a number of ways for nurses to facilitate older people to draw on the four information sources of self-efficacy: performance accomplishments, vicarious learning, verbal encouragement, and physiological and affective states. Research challenges that future studies need to address include the generalisability of exercise setting, the role of age as an effect modifier, and the need for more explicit reporting of how self-efficacy is operationalised in interventions.

Unsupervised walking therapy and atherosclerotic risk-factor management for patients with peripheral arterial disease: a pilot trial

BACKGROUND

Although only a small percentage of patients with peripheral arterial disease (PAD) have claudication, many more suffer from atypical leg symptoms.

PURPOSE

This pilot trial evaluated a risk-factor modification program to improve walking ability in patients with PAD and leg symptoms other than intermittent claudication.

METHODS

Patients 18 years or older with an ankle-brachial index (ABI) of 0.50 to 0.89 completed a baseline assessment of current walking ability, physical activity level, health-related quality of life, glycosylated hemoglobin values, and fasting lipid profiles. Patients were randomized to usual care (control group) versus usual care plus an educational intervention on risk-factor management (intervention group). We compared functional outcomes between and within groups using the Student's t test and control and intervention group outcomes at 12 weeks using analysis of covariance with the baseline value as the covariate.

RESULTS

We randomized 50 patients into two treatment arms. There was no difference in the mean age of patients in each group. At baseline, mean ABI for the control versus the intervention group was 0.72 (SD = 0.10) and 0.75 (SD = 0.10), respectively, and mean stair-climbing values did not differ between groups. At 12 weeks, mean stair-climbing values were 40.2 (SD = 30.2) for the control and 61.2 (SD = 32.8) for the intervention group. The difference in adjusted mean walking distance between groups at 12 weeks was not significant. Analysis of covariance associated assignment to the intervention versus the control arm with a significant increase at 12 weeks in the ABI (p = .008) and stair-climbing ability (p = .02).

CONCLUSIONS

Patients in the intervention group improved objective measures of blood flow and reported stair-climbing ability.

Stages of change for physical activity in adults from Southern Brazil: a population-based survey

Background

There is evidence that physical activity (PA) interventions tailored to individual's stages of change (SoC) are more effective in promote behavior change than "one-size-fits-all" interventions. However, only a few researches have investigated these stages towards PA behavior in representative samples of the population. Thus, the purpose of this study was to determine the prevalence and factors associated with the SoC for PA in a probabilistic sample of adults aged 20 years or over.

Methods

A population-based survey was undertaken in Pelotas, Southern Brazil, in 2005. An algorithm was applied to evaluate the SoC for PA, and PA was defined as being engaged in moderate-to-vigorous PA for at least 20 minutes on three times per week. The covariates collected in the questionnaire were: sex, age, skin color, marital status, education level, economic status, family income, smoking, body mass index (BMI) and self-reported health status. Data analyses were performed through Poisson and multinomial regression, taking the sampling design into account.

Results

Face-to-face interviews were applied to 3136 individuals, corresponding to a response rate of 93.5%. The prevalence across the stages was as follows: 38.3% in precontemplation, 13.0% in contemplation, 19.5% in preparation, 5.2% in action and 24.0% in maintenance. The elderly, married, smokers, and those with lower socioeconomic status were less likely to adopt, initiate and maintain regular PA.

Conclusion

Despite the all benefits of PA, a high proportion of adults from Southern Brazil are physically inactive and do not present intention to engage in regular PA. The profile of those who are inactive but intend to do PA resembles those who are physically active. The findings of the present study can contribute to improve health behaviors and to plan health promotion strategies aimed at increasing the level of PA in the community.

Utility of a Web-based intervention for individuals with type 2 diabetes: the impact on physical activity levels and glycemic control

Despite the numerous benefits of physical activity for patients with diabetes, most healthcare providers in busy clinical settings rarely find time to counsel their patients about it. A Web-based program for healthcare providers can be used as an effective counseling tool, when strategies are outlined for specific stages of readiness for physical activity. Seventy-three adults with type 2 diabetes were randomly assigned to Web-based intervention, printed-material intervention, or usual care. After 12 weeks, the effects of the interventions on physical activity, fasting blood sugar, and glycosylated hemoglobin were evaluated. Both Web-based and printed material intervention, compared with usual care, were effective in increasing physical activity (P < .001) and decreasing fasting blood sugar (P<.01) and glycosylated hemoglobin (P < .01). Post hoc analysis for change scores indicated significant differences between Web-based intervention and usual care and between printed material intervention and usual care, but not between web-based and printed material intervention. The findings of this study support the value of Web-based and printed material interventions in healthcare counseling. With increasing Web access, the effectiveness of Web-based programs offered directly to patients needs to be tested.

Reducing obesity indicators through brief physical activity counseling (PACE) in Italian primary care settings

BACKGROUND

There is an alarming prevalence of obesity and sedentariness in Western countries. An ideal context for health promotion and preventive medicine seems to be the setting of primary care provided by the general practitioner (GP).

PURPOSE

Therefore, this study evaluated the impact of GPs' brief physical activity counseling for overweight and obese patients.

METHODS

Individuals recruited during routine physician visits were randomly split into an experimental (n = 48) group that received the Patient-centered Assessment and Counseling for Exercise (PACE) protocol, and a usual-care control (n = 48) group. Body mass index (BMI) and abdominal girth were assessed as objective biometrical parameters. Patients in the experimental group self-reported their readiness for physical activity and self-efficacy.

RESULTS

The experimental group had significantly better BMI and abdominal girth compared with the control group after a 5- to 6-month follow-up. Furthermore, the experimental group progressed in their stage of physical activity readiness and increased their self-efficacy.

CONCLUSIONS

The GPs' counseling for physical activity using the PACE protocol influenced mediators and biometrical outcomes in an Italian primary care context.

Determinants of older rural women's activity and eating

This research examined the relationship of cognitive-perceptual determinants from the Health Promotion Model to physical activity and healthy eating at baseline of a clinical trial among rural women aged 50 to 69. Two multivariate regression analyses with canonical correlation (N = 179) each yielded one interpretable canonical variate that explained similar amounts of variance (21.7% and 22.5%) in sets of activity and eating variables. In both analyses, the determinants set is a linear combination of all four cognitive-perceptual constructs from the model (perceived self-efficacy, benefits, barriers, interpersonal influences). The activity behavior set included caloric expenditure, VO2max, and stretching and strengthening activity, whereas the eating behavior set included daily percentage of calories from fat and servings of fruits and vegetables, meat, and whole grains. As predicted by theory, greater self-efficacy, benefits and interpersonal support, and fewer barriers are associated with desirable healthy lifestyle behaviors.

Psychosocial Factors Related to Physical Activity and Weight Loss in Overweight Women

PURPOSE

This study examined whether psychosocial factors related to physical activity in overweight, previously sedentary women were affected by a 6-month behavioral weight loss program. In addition, these psychosocial factors were examined across levels of weight loss and self-reported physical activity in response to a weight loss intervention.

METHODS

Data from 165 overweight (body mass index (BMI) = 32.7 +/- 4.2 kg.m(-2)) women (age = 37.6 +/- 5.5 yr) who participated in a comprehensive behavioral weight loss program that included behavioral education, moderate caloric restriction, and progressive home-based exercise were examined. Body weight was assessed at 0 and 6 months. Perceived benefits and barriers, physical activity self-efficacy, and physical activity processes of change were assessed at 0 and 6 months. Physical activity (minutes per week of at least moderate-intensity activity) was assessed using the 7-Day Physical Activity Recall at 0 and 6 months.

RESULTS

The intervention resulted in increases in physical activity self-efficacy, behavioral processes of change, and several cognitive processes of change(P < 0.05). There was a reduction in expected barriers for physical activity (P < 0.05). Individuals with > or = 10% weight loss reported higher levels of physical activity self-efficacy, greater use of behavioral strategies to elicit social support, and fewer barriers to physical activity than those with lower levels of physical activity and less weight loss (P < 0.05). Individuals reporting higher levels of exercise also reported higher levels of physical activity self-efficacy, greater use of behavioral strategies, and fewer barriers to physical activity than those individuals with lower levels of physical activity (P < 0.05).

CONCLUSION

Targeting self-efficacy, behavioral strategies, and barriers in weight management programs may improve physical activity, which may result in improved weight loss in overweight adults.

Active for Life After Cancer: a randomized trial examining a lifestyle physical activity program for prostate cancer patients

BACKGROUND

Active for Life After Cancer is a randomized trial evaluating the efficacy of a 6-month group-based lifestyle physical activity program (Lifestyle) for prostate cancer patients to improve quality of life (QOL) including physical and emotional functioning compared to a group-based Educational Support Program and a Standard Care Program (no group).

METHOD

A total of 134 prostate cancer patients receiving continuous androgen-ablation were randomly assigned to one of the three study conditions.

RESULTS

Results indicated no significant improvements in QOL at 6 or 12 months. Both group-based programs were positively received and yielded good attendance and retention. Lifestyle participants demonstrated significant improvements in most theoretical mediators proposed by the Transtheoretical Model and Social Cognitive Theory to affect physical activity. Despite these improvements, no significant changes were found for most physical activity measures.

CONCLUSIONS

Results suggest a lifestyle program focusing on cognitive-behavioral skills training alone is insufficient for promoting routine physical activity in these patients.

Eligibility for obesity treatment and risk of mortality in men

OBJECTIVE

To evaluate the risk of all-cause and cardiovascular disease (CVD) mortality associated with each outcome of the NIH obesity treatment algorithm and to examine the effects of cardiorespiratory fitness on the risk of mortality associated with these outcomes.

RESEARCH METHODS AND PROCEDURES

The NIH obesity treatment algorithm was applied to 18,666 men (20 to 64 years of age) from the Aerobics Center Longitudinal Study in Dallas, TX, examined between 1979 and 1995. Risk of all-cause and CVD mortality was assessed using Cox proportional hazards regression.

RESULTS

A total of 7029 men (37.7%) met the criteria for needing weight loss treatment [overweight (BMI = 25 to 29.9 kg/m2 or WC > 102 cm) with > or =2 CVD risk factors or obese (BMI > or = 30 kg/m2)]. Mortality surveillance through 1996 identified 435 deaths (151 from CVD) during 191,364 man-years of follow-up. Compared with the normal weight reference group, the hazard ratios (95% confidence interval) for death from all causes were 0.63 (0.45 to 0.88), 1.23 (0.98 to 1.54), 1.05 (0.60 to 1.85), and 1.71 (1.64 to 2.31) for men who were overweight with <2 CVD risk factors, overweight with > or = 2 CVD risk factors, obese with <2 CVD risk factors, and obese with > or =2 CVD risk factors, respectively. Corresponding hazard ratios for CVD mortality were 0.72 (0.38 to 1.37), 1.67 (1.12 to 2.50), 1.69 (0.67 to 4.30), and 3.31 (2.07 to 5.30). Including physical fitness as a covariate significantly attenuated all risk estimates.

DISCUSSION

The NIH obesity treatment algorithm is useful in identifying men at increased risk of premature mortality; however, including an assessment of fitness would help improve risk stratification among all groups of patients.

Effect of a brief antiretroviral adherence intervention delivered by HIV care providers

Antiretroviral therapy (ART) is effective in controlling viral load in many people infected with HIV, but high levels of adherence to ART are needed for prolonged viral suppression. This study evaluated a brief adherence intervention delivered to HIV-positive patients by primary care providers during routine medical examinations. Six clinics were randomly allocated to deliver an intervention focusing on ART adherence (2 clinics) or safer sex (4 clinics). Interventions included written information (posters, brochures, and flyers) and brief counseling from providers and were evaluated with cohorts of randomly selected patients (n = 437) measured before and after a 10-month intervention. Among those 95% or greater adherent at baseline, 91% of patients who received the adherence intervention remained 95% or greater adherent at follow-up compared with 75% of the patients who received the safer sex intervention (chi = 12.59, P < 0.01). This difference was significant in a logistic regression analysis (odds ratio = 2.26; 95% confidence interval = 1.27-4.04), adjusting for baseline adherence, demographics, and HIV medical status. The adherence intervention did not significantly increase the prevalence of 95% or greater adherence among patients less than 95% adherent at baseline. Similar but nonsignificant results were observed for viral load. A brief intervention delivered to HIV patients by their primary providers helped to maintain adequate adherence to ART regimens. More intensive intervention is needed to improve adherence among patients who are initially less than 95% adherent.

Enhancing theoretical fidelity: an e-mail-based walking program demonstration

PURPOSE

To examine the extent to which theoretical fidelity, or precision in replicating theory-based recommendations, influenced the effectiveness of two walking programs based on social cognitive theory (SCT).

DESIGN

Two-group randomized controlled trial.

SETTING

College town in Virginia.

SUBJECTS

Sixty-one sedentary adult women.

INTERVENTION

Two 12-week e-mail-based walking programs were compared. The high fidelity program was designed to more precisely follow SCT recommendations for operationalizing mastery procedures than the low fidelity program, which was designed to simulate how mastery procedures were operationalized in most existing SCT-based physical activity programs. Treatment contact and walking prescription were controlled across groups.

MEASURES

The 1-mile walk test of physical fitness and SCT measures were completed at baseline and posttest. Self-reported walking quantity was assessed at baseline, posttest, and 1-year follow-up. Walking logs were completed during the program. Process evaluation measures were completed at posttest.

RESULTS

Fifty women completed the study. The high fidelity group improved more than twice as much as the low fidelity group on 1-mile walk test time (86 vs. 32 seconds, p < .05), goal setting (p < .05), and positive outcome expectations (p < .05) and reported greater program satisfaction (p < .01).

CONCLUSION

Theoretical fidelity could advance the quality of physical activity interventions, which have often shown small effects.

Tailored versus standard internet-delivered interventions to promote physical activity in older women

PURPOSE

While substantial evidence demonstrates physical activity is effective at reducing risk for cardiovascular and other diseases, the percentage of older women participating in regular activity is low. The Internet offers an alternative method for delivery of a primary prevention intervention. This preliminary study examined the feasibility and effectiveness of using the Internet to deliver behavior change interventions for promoting physical activity in women ages 50-69 years.

METHODS

Thirty-one healthy women (56.1 +/- 4.9 years) were randomly assigned to either tailored or standard newsletter groups. Both groups received 3 Internet-delivered newsletters at baseline, 1 month, and 2 months. Behavioral markers and biomarkers were measured at baseline and postintervention. Post-testing occurred at 3 months (1 month after delivery of the third newsletter).

RESULTS

Repeated measures ANOVAs revealed improvement in measures of flexibility and perceived barriers to exercise for both groups. For the standard group, improvement occurred in % body fat while VO2max declined. Women indicated the newsletters were helpful in influencing behavior change.

CONCLUSION

Internet-delivered newsletters appeared feasible and promising for favorably influencing perceptions about barriers to physical activity in these women. Selfreported physical activity did not increase although selected biomarkers did improve. Whether tailored or standard messaging was more effective was inconclusive.

The effects of physical activity and sedentary behavior on cognitive health in older adults

Physical activity has been shown to be positively associated with cognitive health, but the mechanisms underlying the benefits of physical activity on cognitive health are unclear. The present study simultaneously examined two hypotheses using structural equation modeling (SEM). The depression-reduction hypothesis states that depression suppresses cognitive ability and that physical activity alleviates dysphoric mood and thereby improves cognitive ability. The social-stimulation hypothesis posits that social contact, which is often facilitated by socially laden physical activities, improves cognitive functioning by stimulating the nervous system. Sedentary behavior in the absence of physical activity is expected to exert an inverse relationship on cognitive health through each of these hypotheses. Community-dwelling elders (N = 158) were administered a variety of measures of cognition, depression, social support, and physical activity. SEM techniques provided partial support for the social-stimulation hypothesis and depression-reduction hypothesis. Implications for treating depression and improving cognitive functioning are discussed.

Recommendations for and warnings against physical activity given to older people by health care professionals

BACKGROUND

Little is known about how health care professionals advice older people with chronic conditions about physical exercise. This study investigated exercise counseling in the context of health care as perceived by older people, and factors associated with perceived advice.

DESIGN AND METHODS

Participants were 580 non-institutional 73- to 92-year-old people who reported at least one contact with health care during the previous 12 months.

RESULTS

Of all the participants, 23% recalled solely recommendations to exercise, and 9% solely warnings against exercise. Additionally, 34% recalled receiving both recommendations for and warnings against physical activity, and 34% did not recall exercise-related advice at all. Recalling solely recommendations to exercise was associated with having musculoskeletal diseases and impaired mobility. Reporting solely warnings against physical activity was more common among those having heart conditions. Recalling both recommendations for and warnings against exercise was associated with being physically active despite of having heart conditions, musculoskeletal diseases, and impaired mobility. Recalling no exercise-related advice was most common among people who were sedentary and older, had fewer chronic conditions and reported no mobility limitation.

CONCLUSIONS

A substantial proportion of older people recalled negative, no, or contradicting advice about exercise. As warnings against physical activity may outweigh recommendations to exercise, special attention should be paid to the content of advice in order to avoid discouraging older people from being active.

The positive effect on determinants of physical activity of a tailored, general practice-based physical activity intervention

PACE (Physician-based Assessment and Counseling for Exercise) is an individualized theory-based minimal intervention strategy aimed at the enhancement of regular physical activity. The aim of this study was to evaluate the effectiveness of a PACE intervention applied by general practitioners (GPs) on potential determinants of physical activity. A randomized controlled trial was conducted in 29 general practices with the following inclusion criteria for patients: aged between 18 and 70 years, diagnosed with hypertension, hypercholesterolemia and/or non-insulin-dependent diabetes mellitus, and not in maintenance stage for regular physical activity. The intervention consisted of two visits with the GP and two telephone booster calls by a physical activity counselor. Determinants of physical activity were assessed with questionnaires at baseline, and at 8-week (short), 6-month (medium) and 1-year (long) follow-up. A significant positive effect was observed on self-efficacy, and on the use of cognitive and behavioral processes of change, at both short- and medium-term follow-up. The intervention respondents also perceived fewer barriers for regular physical activity at short-term and used behavioral processes of change more at long-term follow-up. No intervention effect was observed for perceived benefits of physical activity. In conclusion, this GP-based PACE intervention resulted in positive changes in potential determinants of physical activity.

Selecting control interventions for clinical outcome studies

In the current research environment the design and management of control groups is becoming more complex. The selection of a control group design is dependent on study goals, presence and quality of existing interventions, urgency of the problem or issue being addressed by the intervention, and factors related to the study site. The purpose of the presentation is to identify various approaches to the design of control groups in experimental studies and to identify their strengths, limitations, and applications. A case study exemplifies the issues associated with control group selection and design.

The impact of a stage-matched intervention to promote exercise behavior in participants with type 2 diabetes

This study was designed to develop and evaluate a stage-matched intervention (SMI) in Korean participants with type 2 Diabetes. The SMI was based on main constructs derived from the Transtheoretical Model match to the individual's stages of readiness for exercise behavior. The SMI was developed according to the results of the content validity tested by an expert group (n = 9). A control group pre- and post-test design was used for evaluating the impact of the SMI: the intervention group (n = 22) participated in the SMI for 3 months, while the control group (n = 23) received usual educational advice. The intervention group, compared to the control group, showed significant improvements in stages of change for exercise behavior (p < 0.001), physical activity levels (p < 0.001), and reductions in FBS (p < 0.05) and HbA(1)c (p < 0.05). This study yielded evidence for the beneficial impact of the SMI in participants with type 2 Diabetes.

Sedentary lifestyles, physical activity, and cardiovascular disease: from research to practice

More than 60% of the world's population is not physically active at levels that promote health. In concert with other behavioral risk factors for cardiovascular disease (CVD), sedentary lifestyles exact a heavy medical and economic toll on individuals and societies. Physical activity lowers all-cause mortality, reduces several risk factors for cardiovascular disease, and is a category 2 intervention that can halve cardiovascular disease risk. The benefits extend across a wide spectrum of structured as well as lifestyle physical activity levels. Models and programs aimed at translating physical activity's promise in cardiovascular prevention have been assessed, but results have been generally disappointing. A pragmatic strategy based on the "stages of change" or transtheoretical model can be effective. It incorporates self efficacy and individual initiatives, both crucial ingredients necessary to surmount the inevitable hurdles on the path towards physically active lifestyles.

Age, gender, and urban-rural differences in the correlates of physical activity

BACKGROUND

The majority of the population is inactive, and strategies to date for promoting regular physical activity have been limited in their effectiveness. Further research is needed to identify correlates of physical activity in different subgroups to design more efficacious interventions. This study sought to identify correlates of physical activity across men and women, urban and rural geographical locations, and four distinct age groups (18-25; 26-45; 46-59; and 60+).

METHODS

This study employed data from a large provincial household random sample (N = 20,606) of Canadians. Analyses were utilized to examine the amount of variance explained in self-reported physical activity by a number of demographic and/or biological, psychological, behavioral, social, and environmental variables within each subgroup.

RESULTS

Proportion of friends who exercise, injury from past physical activity, educational level, perceived health status, and alcohol consumption were among the strongest correlates across subgroups.

CONCLUSIONS

A number of correlates were identified as being significant across all subgroups examined. Most differences in the correlates of physical activity were found within different age groups rather than among urban and rural residents and gender.

Brief physician advice for high-risk drinking among young adults

BACKGROUND

High-risk alcohol use in persons 18 to 30 years of age is a critical public health problem. It is the number 1 cause of death in this population. This article reports the results of a subanalysis of young adults (aged 18 to 30 years) who participated in Project TrEAT (Trial of Early Alcohol Treatment) conducted in the offices of 64 primary care physicians located in 10 counties in southern Wisconsin.

METHODS

Project TrEAT was a randomized clinical trial designed to test the efficacy of a brief intervention protocol to reduce alcohol use, improve health status, and decrease health care utilization. A total of 226 young adults were randomly assigned to either a usual care or brief intervention group.

RESULTS

There were no significant differences between the 2 groups at baseline on a number of potential confounders. During the 4-year follow-up period, there were significant reductions in number of persons drinking more than 3 drinks per day, average 7-day alcohol use, number of persons drinking 6 or more drinks per occasion, and number of binge drinking episodes in the previous 30 days (P < .01 to P < .001). There were also significant differences (P < .05) in emergency department visits (103 vs 177), motor vehicle crashes (9 vs 20), total motor vehicle events (114 vs 149), and arrests for controlled substance or liquor violation (0 vs 8).

CONCLUSION

In this 4-year subanalysis of young adults who participated in Project TrEAT, we found long-term reductions in high-risk drinking behaviors and consequences. The findings of this study support more widespread implementation of brief interventions in primary care settings.

Readiness to change physical activity and dietary practices and willingness to consult healthcare providers

Background

Complementary or discrepant stages of change for multiple risk behaviors can guide the development of effective risk reduction interventions for multiple risk factors. The objectives of this study were to assess readiness to change physical activity and dietary practices and the relationships among readiness scores for physical activity and dietary practices. In an underserved population, the readiness scores were analyzed in relationship to the patient's interest in communicating with healthcare providers about health behavior change. Healthcare providers are important contributors in promoting behavior change in community health centers.

Methods

Patients completed questionnaires about communicating with healthcare providers and readiness to change physical activity, intake of fruits and vegetables, dietary fat, calories and weight management. Frequency distributions, correlations, and analysis of variance were computed.

Results

Readiness to change physical activity was not related to readiness to change dietary practices. Readiness to change fruit and vegetable intake and readiness to change dietary fat intake were significantly related. Readiness to change and interest in communicating with healthcare providers were significantly related for physical activity but not for dietary practices.

Conclusions

Readiness to change behavior and interest in talking to healthcare providers were distinct dimensions; for physical activity, the dimensions were congruent and for dietary practices, the dimensions were unrelated. Readiness to change physical activity and dietary practices were not related (discrepant stages of readiness). Therefore, among underserved populations, sequential rather than simultaneous interventions may be appropriate when intervening on multiple risk behaviors, particularly physical activity and dietary practices.

Stage-based lifestyle interventions in primary care: are they effective?

BACKGROUND

To systematically review the literature concerning the effect of stages-of-change-based interventions in primary care on smoking, physical activity, and dietary behavior.

METHODS

An extensive search (until July 2002) was performed using the following inclusion criteria: (1) (randomized) controlled trial (RCT/CT), (2) intervention initiated in primary care, (3) and intervention aimed at changing smoking, physical activity, or dietary behavior, and stages-of-change-based outcomes, and (4) behavioral outcomes. Methodologic quality was assessed, and conclusions on the effectiveness at short-, medium-, and long-term follow-up were based on a rating system of five levels of evidence. Odds ratios were calculated when methodologically appropriate.

RESULTS

A total of 29 trials were selected for inclusion. Thirteen studies included a physical activity intervention, 14 aimed at smoking cessation, and five included a dietary intervention. Overall methodologic quality was good. No evidence was found for an effect on stages of change and actual levels of physical activity. Based on the strength of the evidence, limited to no evidence was found for an effect on stages of change for smoking and smoking quit rates. Odds ratios for quitting smoking showed a positive trend. Strong evidence was found for an effect on fat intake at short- and long-term follow-up. Limited evidence was found for an effect on stages of change for fat intake at short-term follow-up.

CONCLUSIONS

The scientific evidence for the effect of stages-of-change-based lifestyle interventions in primary care is limited. Limiting aspects in the stages-of-change concept with respect to complex behaviors as physical activity and dietary behavior are discussed.

Medical students' readiness to provide lifestyle counseling for overweight patients

In order to assess medical students' readiness to engage in lifestyle counseling regarding nutrition, physical activity, and other health behaviors, the authors examined the knowledge, attitudes, and health behaviors of medical students. The authors analyzed questionnaire responses of 290 medical students in their first, second, or third year. Students were generally knowledgeable about cardiovascular disease risk factors, however they were less knowledgeable about body mass index (BMI) and specific nutrition and physical activity recommendations. Students were confident in the ability of physicians to change patients' health behaviors and had positive attitudes about providing lifestyle counseling. The upper-level students held significantly less positive attitudes than the first-year students. Almost half the sample reported regularly making unhealthy dietary choices. Only 23% of the sample met the public health guidelines for accumulating 30 min of moderate activity on at least 5 days a week. Third-year students engaged in significantly less activity than their underclassmen. Although medical students express positive attitudes toward providing lifestyle counseling, they require more instruction in the areas of weight screening, nutrition, and physical activity recommendations in order to be helpful to their patients. Because physicians who practice health behaviors are more likely to provide counseling, it would be beneficial to integrate an emphasis on student health into medical curricula.

Efficacy of a Multicomponent Program (Patient-Centered Assessment and Counseling for Exercise plus Nutrition [PACE+ Japan]) for Lifestyle Modification in Patients with Essential Hypertension

With conventional lifestyle modification programs, it can be difficult for hypertensive individuals to modify their lifestyles and maintain the changes. We assessed whether a multicomponent program (patient-centered assessment and counseling for exercise plus nutrition [PACE+ Japan]) based on behavior theory and social cognitive theory would be effective for treating patients with essential hypertension. We examined 57 outpatients aged 62+/-10 years with essential hypertension irrespective of antihypertensive drug treatment. Participants were randomly divided into two groups: 1) a PACE+ Japan follow-up group (n =18), who were given an action-plan sheet and systemic health counseling by a physician and counselor every 4 weeks for 24 weeks, and 2) a PACE+ Japan-only group (n =20), who were given an action-plan sheet but did not receive counseling. An age- and sex-matched control group (n =19) was also selected. The decrease in systolic blood pressure (SBP) (Delta SBP=SBP at 24 weeks minus that at 0 weeks) in the PACE+ Japan follow-up group was significantly greater than that in the control group. In addition, the Delta percentage of Fat (%Fat) and Delta urinary sodium extraction (U-Na) in the PACE+ Japan follow-up group were significantly greater than those in the control group. With regard to changes in total energy expenditure, exercise energy expenditure and total energy intake between 0 weeks and 24 weeks, significant improvements were observed for the PACE+ Japan follow-up group. Delta U-Na was determined to significantly predict Delta SBP as assessed by stepwise selection. In addition, the partial correlation coefficient of Delta SBP with Delta U-Na was 0.361 (p =0.011) as assessed by a multiple regression analysis. Therefore, PACE+ Japan follow-up counseling was associated with a reduction in SBP, which in turn was associated with reduction in U-Na. This new program may be effective for reducing blood pressure in hypertensives.

Developing an empirical typology for regular exercise

BACKGROUND

Tailored interventions require the identification of distinct homogenous subgroups that will benefit from different intervention materials. One way to identify such subgroups is to use cluster analysis to identify an empirical typology.

METHODS

A sample of 346 adults completed surveys through a telephone interview that included questions related to participating in regular exercise. The three variables used in the cluster analysis were the Pros of Exercise, the Cons of Exercise, and Exercise Self-Efficacy.

RESULTS

Six resulting clusters were labeled Disengaged, Immotive, Relapse Risk, Early Action, Maintainers, and Habituated. A series of analyses tested the internal and external validity of the typology. The internal validity test revealed that four of the clusters demonstrated high stability and replicability, while the Relapse Risk and Early Action clusters were less stable. Differences among clusters on self-reported exercise behavior and a strong association with stage of change for regular exercise provided external validity evidence of the typology.

CONCLUSIONS

The resulting typology reflects a range of motivational patterns that are likely to be responsive to different types of messages and strategies regarding adoption and maintenance of regular exercise. The typology also generates a number of hypotheses about the identified clusters that can be empirically tested in further studies.

Older women and exercise: explanatory concepts

BACKGROUND

Older women remain predominantly sedentary despite potential health benefits and reduced risks of cardiovascular disease associated with regular exercise. Primary care interventions to increase exercise need to focus on constructs amenable to intervention that predict exercise behavior.

PURPOSE

The study tested an explanatory model of older women's exercise behavior using concepts from social cognitive theory, the transtheoretical model, and the theory of planned behavior (self-efficacy, outcome expectancy, perceived exercise barriers, processes of change, perceived health, and age).

METHODS

Data were collected by interviews with 203 older community-dwelling women physically capable of some exercise. Ordinary least squares regression results were used to determine the direct and indirect effects in a path model.

FINDINGS

All concepts and 13 hypothesized paths were retained in the trimmed model. The constructs accounted for 46% of the variance in exercise behavior. Outcome expectancy had the largest total effect. Processes of change had the largest direct effect on exercise behavior. Exercise self-efficacy and perceived exercise barriers accounted for similar amounts of variance in exercise behavior, whereas age and health had only modest effects.

CONCLUSION

Important constructs for future exercise model testing and intervention research should include outcome expectancy, processes of change, exercise self-efficacy, and perceived barriers to exercise. Primary care interventions designed to increase older women's exercise should focus on these same constructs.

Exercise counselling by family physicians in Canada

BACKGROUND

Exercise counselling is not frequently conducted by family physicians in several countries. Little is known about the exercise counselling practices of family physicians in Canada. The objective of this study was to assess physician confidence, current versus desired practice, and barriers related to the counselling of exercise by family physicians in Canada.

METHODS

The study was a cross-sectional survey that included a random selection of family physicians in six provinces. A total of 330 family physicians completed the questionnaire, resulting in a response rate of 61.1%. A family physician was defined as a physician who practices family medicine at least 75% of their practice time.

RESULTS

A total of 58.2% believed only 0-25% of their patients would respond to their counselling and 42.4% felt "moderately knowledgeable" to exercise counsel. Only 11.8% counselled 76-100% of their patients about exercise, but 43.3% thought they should be counselling 76-100% of their patients. Barriers to exercise counselling that rated most important included lack of time (65.7%) and lack of exercise education in medical school (64.8%).

CONCLUSIONS

Family physicians indicated their current level of exercise counselling is suboptimal and confidence levels in exercise counselling were not high. Future educational opportunities for physicians may assist in improving exercise counselling.

The effect of advice by health care professionals on increasing physical activity of older people

The aim of this study was to investigate whether advice by health care professionals is associated with increased exercise activity in older people. As part of the Evergreen follow-up study, self-report data on exercise related advice were collected in 1996 and physical activity in 1988 and 1996 among 611 non-institutional people initially aged 65-84 years. Logistic regression analyses were used to study the association of recollection of having received exercise counseling with increased activity. Of all the subjects, 92% reported having been in contact with health care professionals during the follow-up period, and 58% of them recalled having been advised to exercise. Those men and women who recalled having received advice, started to participate in supervised exercise classes 5-6 times more often than those who did not recall being advised. The odds ratio (95% confidence interval) in men was 6.27 (1.19-32.9), and in women 5.27 (1.97-14.1). For calisthenics at home, the corresponding figure was 12.5 (3.52-44.4) in men. We concluded that initiating new physical activities in old age is strongly connected to encouragement to exercise by health care professionals. Health care professionals should be supported to promote exercise among older patients.

Biopsychosocial characteristics of overweight and obese primary care patients: do psychosocial and behavior factors mediate sociodemographic effects?

BACKGROUND

The increasing prevalence of obesity and obesity-related conditions in primary care settings challenges the health care system. Thus, we used available baseline data from an on-going clinical trial to examine the biopsychosocial characteristics of overweight and obese primary care patients. The primary research objective was to ascertain whether theoretically important psychosocial and behavioral variables mediate the empirical relationships between sociodemographic factors and body mass index (BMI).

METHODS

Overweight or obese primary care patients (n=665) enrolled in an on-going trial of a cognitive-behavioral obesity intervention provided baseline sociodemographic, psychosocial, nutritional, physical activity, and anthropometric data that were analyzed via multiple regression.

RESULTS

Lower educational attainment was associated with a higher BMI after controlling for decisional balance, social support, self-efficacy, energy intake, and energy expenditure (P<0.05). In contrast, ethnicity was not associated with BMI after controlling for the psychosocial and behavioral variables. Decisional balance and social support variables were associated with BMI and energy intake, but the directions of some of the associations were not consistent with a priori expectations.

CONCLUSIONS

Overall, we found some evidence of mediation by the psychosocial and behavioral variables of the relationship between ethnicity and BMI, but not for the relationship between education and BMI. In addition, some of the relationships between the psychosocial variables and BMI were opposite of our expectations.

Are activity promotion interventions based on the transtheoretical model effective? A critical review

The health benefits of physical activity are well documented yet 70% of adults remain sedentary. It has been suggested that interventions based on the transtheoretical model of behaviour change (TTM) may be useful in promoting physical activity. Published work on the effectiveness of such interventions is therefore critically reviewed. Although there is evidence that TTM based activity promotion interventions are effective in promoting activity adoption, initial results on longer term adherence are disappointing.

Key elements for church-based health promotion programs: outcome-based literature review

Although not a new concept, church-based health promotion programs have yet to be widely researched. Few of the initial studies used randomized and controlled designs. Dissemination of study results has been sporadic, with findings often reported in church periodicals. A renewed interest in church-based health promotion programs (CBHPP) is emerging. The purpose of this article is to propose seven key elements found in a literature review to be beneficial in establishing church-based community health promotion programs that demonstrated desired health promotion outcomes. Based on the outcomes of successful CBHPP, the following key elements have been identified: partnerships, positive health values, availability of services, access to church facilities, community-focused interventions, health behavior change, and supportive social relationships. An example of one program that embodies these elements is presented. The Heart and Soul Program, designed to increase physical activity in midlife women to reduce their risk of cardiovascular disease with advancing age, is discussed within the context of the elements for successful church-based programs. CBHPP have effectively promoted health behaviors within certain communities. To promote health and wellness in light of our diverse society and health needs, health promotion professionals and churches can be dynamic partners.

Theoretical approaches to the promotion of physical activity: forging a transdisciplinary paradigm

BACKGROUND

Research in the physical activity promotion arena has focused on the application of theoretical perspectives aimed primarily at personal levels of understanding and analysis. The investigation of such theories has provided some insights related to potentially useful mediators of physical activity behavior. However, to continue to expand this field, new perspectives on personal-level theories, in addition to the exploration of more macro-level conceptual perspectives, are required.

OBJECTIVE

The purpose of this article is to: (1) briefly review the current strengths and limitations of the personal-level, physical activity-theory literature; and (2) introduce concepts and perspectives from other fields, including the social-ecology and urban-planning fields, of potential relevance to the physical activity arena.

METHOD

We provide an overview of potentially relevant theoretical perspectives aimed at different levels of understanding and analysis, from the personal level through the broader-scale meso- and macro-environmental perspectives. In addition, we suggest initial steps to take in developing a transdisciplinary paradigm encompassing all such levels of analysis and investigation.

CONCLUSIONS

Given the scope of the physical inactivity epidemic facing the U.S. population currently and in the future, methods and approaches that integrate theory and concepts across a broader group of disciplines will be increasingly necessary.