The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care

A structured review of the effect of economic incentives on consumers' preventive behavior

Improving participation in preventive activities will require finding methods to encourage consumers to engage in and remain in such efforts. This review assesses the effects of economic incentives on consumers' preventive health behaviors. A study was classified as complex preventive health if a sustained behavior change was required of the consumer; if it could be accomplished directly (e.g., immunizations), it was considered simple. A systematic literature review identified 111 randomized controlled trials of which 47 (published between 1966 and 2002) met the criteria for review. The economic incentives worked 73% of the time (74% for simple, and 72% for complex). Rates varied by the goal of the incentive. Incentives that increased ability to purchase the preventive service worked better than more diffuse incentives, but the type matters less than the nature of the incentive. Economic incentives are effective in the short run for simple preventive care, and distinct, well-defined behavioral goals. Small incentives can produce finite changes, but it is not clear what size of incentive is needed to yield a major sustained effect.

Cardiovascular risk factors and motivation for a healthy life-style in a German community--results of the GP-based Oestringen study

This paper explores the motivation of patients towards a healthy life-style in a small community with a special general practice and community-based health education program in order to identify reasons for different motivations and barriers and to improve preventive measures and outcome. The last of six standardised health surveys carried out over 9 years in the five general practices was therefore combined with a questionnaire to explore the attitudes of a sample of patients from these practices (N = 1044) and all attendees of 11 health education courses (N = 153). In addition to the cardiovascular risk factors, data were collected on sociodemographic factors and motivations for health promotion. The results show that, over time, the risk factors of hypertension (P < 0.001) and smoking (P < 0.005) had decreased. Health-promoting activities were not associated with cardiovascular risk factors; the motivations "duty" and "staying young" correlated with gender (P < 0.05). Patients with good health and white collar professions were more active. About 20% specified specific barriers to health-related activities. As expected, the participants of an educational program were more highly motivated by "fun", "fitness" and "meaningfulness". This group was mainly female. Future preventive measures should take into account that motivation for health promotion depends more on psychosocial factors than on risk factors; frequent obstacles should be noticed in the community.

The Emerging Evidence Base for Motivational Interviewing: A Meta-Analytic and Qualitative Inquiry

This article offers a meta-analytic, qualitative, and process review of the empirical literature for adaptations of motivational interviewing (AMIs), a promising approach to treating problem behaviors. AMIs are equivalent to other active treatments and yield moderate effects (from 0.35 to 0.56) compared to no-treatment/placebo for problems involving alcohol, drugs, and diet and exercise. Results do not support the efficacy of AMIs for smoking or HIV-risk behaviors. Conclusions regarding the mechanisms of action for AMIs are limited by methodological problems: confounding motivational interviewing with feedback, unclear definitions of the AMI interventions used, difficulties in therapist training, and limited use of treatment integrity rating scales. Extant research suggests that AMIs are equivalent in efficacy to and briefer than cognitive behavioral skills training (CBST) approaches. Since AMIs focus on readiness to change while CBST targets the change process, AMIs may be useful as preludes or additions to CBST.

Promotion of physical activity in primary health care: update of the evidence on interventions

This review provides an update of the evidence on the impact of physical activity (PA) interventions for patients in primary health care services. Sixteen studies published since 1999 are included. Twelve studies tested interventions of PA only and yielded good evidence that these can have a short-term (< 6 mths) impact upon behaviour. Four studies tested multiple risk factor interventions with a PA component, but the findings from these were inconclusive. There were insufficient studies to identify the attributes of effective interventions, but both brief and intensive single risk factor interventions produced short-term increases in PA. Little attention has been given in the research to the representativeness of study participants or intervention deliverers, or the potential for interventions to be transferred into routine service delivery. In light of current evidence, a reasonable approach for primary care practitioners is to undertake brief PA interventions with patients with health problems who could benefit from increased PA. Future research should pay greater attention to elements of study and intervention designs, including reach, adoption by practitioners and implementation within existing service structures, so that the public health potential of the findings can be realised.

Changing the individual to promote health-enhancing physical activity: the difficulties of producing evidence and translating it into practice

This paper presents conclusions from recent systematic reviews and highlights individually targeted interventions that are effective at increasing physical activity. It discusses the limitations of currently available evidence, considers what factors lead to these limitations and what barriers exist in terms of implementing the evidence as part of local and national policy and practice. Barriers present themselves in terms of getting evidence into practice and in terms of ensuring that practice informs the evidence base. These barriers include difficulties in conducting systematic reviews, disaggregating knowledge from complex interventions, making local adaptations to existing evidence, the lack of an evaluation culture, ethical and pragmatic difficulties in designing interventions, selecting appropriate outcome measures, poor designs and implementation of evidence and, finally, a recognition that policy making is not only based on the available evidence. New and more integrated approaches to evaluation and to practice are needed.

How general practitioners promote 'lifestyle' physical activity

We investigated how General Practitioners (GPs) promote lifestyle physical activity (PA) ('accumulate 30 min of at least moderate PA on 5 or more days per week': PA30 x 5) to patients in the different stages of change, using a range of counselling strategies. These strategies included six 'A' factors (Ask, Assess, Advise, Assure, Arrange a follow-up, and Applaud). In a postal questionnaire (68% return rate), 47% of GPs from a single UK health district reported regularly promoting PA30 x 5. A stepwise logistic regression identified three counselling strategies that predicted regularly promoting PA30 x 5: (1) arrange follow-ups for patient pre-contemplators (OR=4.93), (2) patient contemplators passed to GP exercise referral scheme (OR=2.34), and (3) asking relapsers about their PA30 x 5 (OR=2.61). GPs who regularly promote PA30 x 5 base their counselling on patients' pre-existing PA behaviour, using 'effortful', 'stage-matched' approaches. Since these are acceptable to GPs, in-service training may build on using these three factors.

A new evidence-based model for weight management in primary care: the Counterweight Programme

BACKGROUND/AIMS

Obesity has become a global epidemic, and a major preventable cause of morbidity and mortality. Management strategies and treatment protocols are however poorly developed and evaluated. The aim of the Counterweight Programme is to develop an evidence-based model for the management of obesity in primary care.

METHODS

The Counterweight Programme is based on the theoretical model of Evidence-Based Quality Assessment aimed at improving the management of obese adults (18-75 years) in primary care. The model consists of four phases: (1) practice audit and needs assessment, (2) practice support and training, (3) practice nurse-led patient intervention, and (4) evaluation. Patient intervention consisted of screening and treatment pathways incorporating evidence-based approaches, including patient-centred goal setting, prescribed eating plans, a group programme, physical activity and behavioural approaches, anti-obesity medication and weight maintenance strategies. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation. Eighty practices were recruited of which 18 practices were randomized to act as controls and receive deferred intervention 2 years after the initial audit.

RESULTS

By February 2004, 58 of the 62 (93.5%) intervention practices had been trained to run the intervention programme, 47 (75.8%) practices were active in implementing the model and 1256 patients had been recruited (74% female, 26% male, mean age 50.6 years, SD 14). At baseline, 75% of patients had at one or more co-morbidity, and the mean body mass index (BMI) was 36.9 kg/m(2) (SD 5.4). Of the 1256 patients recruited, 91% received one of the core lifestyle interventions in the first 12 months. For all patients followed up at 12 months, 34% achieved a clinical meaningful weight loss of 5% or more. A total of 51% of patients were classed as compliant in that they attended the required level of appointments in 3, 6, and 12 months. For fully compliant patients, weight loss improved with 43% achieving a weight loss of 5% or more at 12 months.

CONCLUSION

The Counterweight Programme is an evidence-based weight management model which is feasible to implement in primary care.

Motivational interviewing in health settings: a review

There is evidence that patient-centred approaches to health care consultations may have better outcomes than traditional advice giving, especially when lifestyle change is involved. Motivational interviewing (MI) is a patient-centred approach that is gathering increased interest in health settings. It provides a way of working with patients who may not seem ready to make the behaviour changes that are considered necessary by the health practitioner. The current paper provides an overview of MI, with particular reference to its application to health problems.

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.

Updating the evidence relating to physical activity intervention studies in older people

For older adults, physical activity (PA) plays a central role in the prevention and management of chronic disease, and has the potential to reduce physical decline, maintain functional ability and prevent injuries. This review provides an update of the evidence relating to the effectiveness of PA intervention studies (both general PA and trials specific to progressive resistance training (PRT)) for older adults. The following electronic databases were searched for articles published since 1999: Medline, PubMed, EMBASE, CINAHL and Sport Discus. For the PRT section, a 2002 Cochrane review was also used. Eight general PA intervention studies were included in this review, ranging from one-on-one counselling in general practice to the community-wide promotion of walking. The aim of most of the trials was to increase moderate and/or vigorous activity levels. Most of the studies reviewed had some degree of success in getting older people to be more active. However, a major limitation was the use of self-report measures of PA. The review of PRT interventions included 21 trials. Participants in half the studies had either functional limitations or a chronic condition. Most trials were conducted in a supervised setting using specialised equipment. Increased strength and improvement in basic functional tasks were generally reported, but there was a paucity of strong evidence linking PRT with reduced physical disability and improved health-related quality of life. While considerable progress is being made in this area, further population-based studies that include home and whole-community interventions are required.

A randomised controlled trial of three pragmatic approaches to initiate increased physical activity in sedentary patients with risk factors for cardiovascular disease

BACKGROUND

Physical activity is a major modifiable risk factor for cardiovascular disease, but it is unclear what combination of feasible approaches, using existing resources in primary care, work best to initiate increased physical activity.

AIM

To assess three approaches to initiate increased physical activity.

DESIGN OF STUDY

Randomised controlled (2 X 2 X 2) factorial trial.

SETTING

Four general practices.

METHOD

One hundred and fifty-one sedentary patients with computer documented risk factors for cardiovascular disease were randomised to eight groups defined by three factors: prescription by general practitioners (GPs) for brisk exercise not requiring a leisure facility (for example, walking) 30 minutes per day, 5 days per week; counselling by practice nurses, based on psychological theory to modify intentions and perceived control of behaviour, and using behavioural implementation techniques (for example, contracting, 'rehearsal'); use of the Health Education Authority booklet 'Getting active, feeling fit'.

RESULTS

Single interventions had modest effects. There was a trend from the least intensive interventions (control +/- booklet) to the more intensive interventions (prescription and counselling combined +/- booklet) for both increased physical activity and fitness (test for trend, P = 0.02 and P = 0.05, respectively). Only with the most intense intervention (prescription and counselling combined) were there significant increases in both physical activity and fitness from baseline (Godin score = 14.4, 95% confidence interval [CI] = 7.8 to 21, which was equivalent to three 15-minute sessions of brisk exercise and a 6-minute walking distance = 28.5 m, respectively, 95% CI = 11.1 to 45.8). Counselling only made a difference among those individuals with lower intention at baseline.

CONCLUSION

Feasible interventions using available staff, which combine exercise prescription and counselling explicitly based on psychological theory, can probably initiate important increases in physical activity.

Can primary care doctors prescribe exercise to improve fitness? The Step Test Exercise Prescription (STEP) project

BACKGROUND

Sedentary lifestyle is associated with adverse health outcomes. Available evidence suggests that, despite positive attitudes toward regular exercise in promoting a healthy lifestyle, few physicians actually prescribe exercise for their patients. Barriers include lack of skills and standard office instruments. Because primary care physicians have regular contact with a large proportion of the population, the impact of preventive health interventions may be great.

OBJECTIVES

To determine the effect of an exercise prescription instrument (i.e., Step Test Exercise Prescription [STEP]), compared to usual-care exercise counseling delivered by primary care doctors on fitness and exercise self-efficacy among elderly community-dwelling patients.

DESIGN

Randomized controlled trial; baseline assessment and intervention delivery with postintervention follow-up at 3, 6, and 12 months.

SETTING

Four large (>5000 active patient files) academic, primary care practices: three in urban settings and one in a rural setting, each with four primary care physicians; two clinics provided the STEP intervention and two provided usual care control.

PARTICIPANTS

A total of 284 healthy community-dwelling patients (72 per clinic) aged >65 years were recruited in 1998-1999.

INTERVENTION

STEP included exercise counseling and prescription of an exercise training heart rate.

MAIN OUTCOME MEASURES

The primary outcome measure was aerobic fitness (VO(2max)). Secondary outcomes included predicted VO(2max) from the STEP test, exercise self-efficacy (ESE), and clinical anthropometric parameters.

RESULTS

A total of 241 subjects (131 intervention, 110 control) completed the trial. VO(2max) was significantly increased in the STEP intervention group (11%; 21.3 to 24ml/kg/min) compared to the control group (4%; 22 to 23ml/kg/min) over 6 months (p <0.001), and 14% (21.3 to 24.9ml/kg/min) and 3% (22.1 to 22.8ml/kg/min), respectively, at 12 months (p <0.001). A similar significant increase in ESE (32%; 4.6 vs 6.8) was observed for the STEP group compared to the control group (22%; 4.2 vs 5.4) at 12 months (p < 0.001). Systolic blood pressure decreased 7.3% and body mass index decreased 7.4% in the STEP group, with no significant change in the control group (p <0.05). Exercise counseling time was significantly (p <0.02) longer in the STEP (11.7+/-3.0 min) compared to the control group (7.1+/-7.0 min), but more (p <0.05) subjects completed > or =80% of available exercise opportunities in the STEP group.

CONCLUSIONS

Primary care physicians can improve fitness and exercise confidence of their elderly patients using a tailored exercise prescription (e.g., STEP). Further, STEP appears to maintain benefits to 12 months and may improve exercise adherence. Future study should determine the impact of combining cognitive/behavior change strategies with STEP.

Effectiveness of counselling patients on physical activity in general practice: cluster randomised controlled trial

OBJECTIVE

To assess the long term effectiveness of the "green prescription" programme, a clinician based initiative in general practice that provides counselling on physical activity.

DESIGN

Cluster randomised controlled trial. Practices were randomised before systematic screening and recruitment of patients.

SETTING

42 rural and urban general practices in one region of New Zealand.

SUBJECTS

All sedentary 40-79 year old patients visiting their general practitioner during the study's recruitment period.

INTERVENTION

General practitioners were prompted by the patient to give oral and written advice on physical activity during usual consultations. Exercise specialists continued support by telephone and post. Control patients received usual care.

MAIN OUTCOME MEASURES

Change in physical activity, quality of life (as measured by the "short form 36" (SF-36) questionnaire), cardiovascular risk (Framingham and D'Agostino equations), and blood pressure over a 12 month period.

RESULTS

74% (117/159) of general practitioners and 66% (878/1322) of screened eligible patients participated in the study. The follow up rate was 85% (750/878). Mean total energy expenditure increased by 9.4 kcal/kg/week (P=0.001) and leisure exercise by 2.7 kcal/kg/week (P=0.02) or 34 minutes/week more in the intervention group than in the control group (P=0.04). The proportion of the intervention group undertaking 2.5 hours/week of leisure exercise increased by 9.72% (P=0.003) more than in the control group (number needed to treat=10.3). SF-36 measures of self rated "general health," "role physical," "vitality," and "bodily pain" improved significantly more in the intervention group (P<0.05). A trend towards decreasing blood pressure became apparent but no significant difference in four year risk of coronary heart disease.

CONCLUSION

Counselling patients in general practice on exercise is effective in increasing physical activity and improving quality of life over 12 months.

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.

Motivation for health behaviours: a systematic review of the nursing literature

AIMS AND RATIONALE: This research review examines nursing and allied health studies exploring motivation for health behaviours to identify the state of understanding of this construct within nursing. This review contributes to nursing science by synthesizing nursing research regarding motivation for health behaviour.

METHODS

Integrative research review methodology.

FINDINGS

Problems of existing research include nonprobability sampling of heterogeneous populations, low statistical power, and colinearity. Studies identifying predictors of motivation explained large proportions of variance using regression. Motivation was not a significant predictor of health behaviours for over one-third of the studies. Overall, the studies suggest that either motivation is not being effectively measured because of a lack of conceptual clarity or that motivation is not an essential determinant of health behaviours. The latter cannot be verified until psychometric research advances current measurement of motivation to a higher level. LIMITATIONS; The literature for this review was accessed through the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database. Databases for other disciplines were not included in this search. This work represents a first step towards understanding motivation for health behaviour as it is currently defined in the literature. Future studies are necessary to broaden this understanding beyond nursing.

CONCLUSIONS

Motivation is a frequently cited rationale underlying the adoption and maintenance of health behaviours in research and practice. Motivation is complex and multidimensional, and clearer definitions for motivation are needed. Populations that have been underrepresented in motivation research need to be targeted in future research. Researchers and practitioners are challenged to examine carefully the role of motivation for health behaviours and explore other factors that may more strongly influence health behaviours.

Primary prevention of disease of old age

Although increasing disability is a common concomitant of old age, several interventions may prevent or delay disabling diseases. The "young-old" differ little from middle-aged people in their potential to benefit from many interventions. As age increases, clinicians need to become increasingly circumspect about interventions with a potential for harm and for benefit. By carefully weighing existing disease burden, the state of our knowledge about prevention, and patient values, however, clinicians may develop a reasonable preventive program in consultation with the patient and, where there is diminished competence, relevant family members. As we gain new knowledge about genetic and other risk factors, we may be able to more accurately and effectively target preventive services to maximize benefits and minimize harms in the population as a whole.

Advising people to take more exercise is ineffective: a randomized controlled trial of physical activity promotion in primary care

BACKGROUND

Over the last 10 years 'exercise referral schemes' have been popular even though the evidence for effectiveness of any one-to-one intervention in primary care is deficient. We report the results of a primary care based one-to-one intervention that compared the effect of two communication styles with a no-intervention control group on self-reported physical activity at 12 months.

METHODS

In all, 1658 middle-aged men and women were randomly assigned to 30 minutes of brief negotiation or direct advice in primary care or a no-intervention control group. The main outcome was self-reported physical activity at 12 months. Secondary outcome measures included change in blood pressure and body mass index.

RESULTS

Intention-to-treat analysis revealed no significant differences in physical activity between groups. Brief negotiation group participants who completed the study increased their physical activity significantly more than controls. There was no change in body mass index in any group. The brief negotiation group produced a greater reduction in diastolic blood pressure than direct advice.

CONCLUSION

If patients whose health may benefit from increased physical activity seek advice in primary care, 20-30 minutes of brief negotiation to increase physical activity is probably more effective than similar attempts to persuade or coerce. However, blanket physical activity promotion in primary care is not effective. The most effective way of increasing physical activity in primary care has yet to be determined.

Can lay-led walking programmes increase physical activity in middle aged adults? A randomised controlled trial

STUDY OBJECTIVE

To compare health walks, a community based lay-led walking scheme versus advice only on physical activity and cardiovascular health status in middle aged adults.

DESIGN

Randomised controlled trial with one year follow up. Physical activity was measured by questionnaire. Other measures included attitudes to exercise, body mass index, cholesterol, aerobic capacity, and blood pressure.

SETTING

Primary care and community.

PARTICIPANTS

260 men and women aged 40-70 years, taking less than 120 minutes of moderate intensity activity per week.

MAIN RESULTS

Seventy three per cent of people completed the trial. Of these, the proportion increasing their activity above 120 minutes of moderate intensity activity per week was 22.6% in the advice only and 35.7% in the health walks group at 12 months (between group difference =13% (95% CI 0.003% to 25.9%) p=0.05). Intention to treat analysis, using the last known value for missing cases, demonstrated smaller differences between the groups (between group difference =6% (95% CI -5% to 16.4%)) with the trend in favour of health walks. There were improvements in the total time spent and number of occasions of moderate intensity activity, and aerobic capacity, but no statistically significant differences between the groups. Other cardiovascular risk factors remained unchanged.

CONCLUSIONS

There were no significant between group differences in self reported physical activity at 12 month follow up when the analysis was by intention to treat. In people who completed the trial, health walks was more effective than giving advice only in increasing moderate intensity activity above 120 minutes per week.

Exercise discussions during cancer treatment consultations

PURPOSE

Physical exercise has been shown to help cancer survivors cope with treatment side effects. The purpose of this study was to examine the role of the oncologist in promoting exercise in cancer survivors.

DESCRIPTION OF STUDY

Cancer survivors who had recently completed treatment (N = 311) were mailed a self-administered questionnaire that assessed the following: whether exercise was discussed during any of their treatment consultations; whether they preferred that exercise be discussed during this time; their perceived oncologist approval for exercise; and the amount of exercise they performed during treatment.

RESULTS

Descriptive statistics showed that 28.4% of cancer survivors reported that their oncologist initiated a discussion of exercise during their treatment consultation, that 13.9% said that they initiated a discussion, and that 57.8% said that exercise was not discussed. Survivors younger than 60 years of age were more likely to initiate a discussion of exercise than were older survivors. Survivors whose oncologist initiated a discussion of exercise also reported a stronger normative belief for exercise, performing more frequent exercise during treatment, and performing more total minutes of exercise during treatment. Most (82.2%) survivors preferred that the oncologist initiate the discussion of exercise.

CLINICAL IMPLICATIONS

These findings indicate that most cancer survivors responding to this survey preferred that their oncologist initiate a discussion of exercise. Such a discussion appears to increase survivor exercise levels during treatment. If confirmed in a prospective, randomized, controlled trial, the implication is that an oncologist-initiated discussion of exercise during treatment consultations may be a cost-effective strategy for promoting exercise in cancer survivors.

Caring for the health of the public: cross sectional study of the activities of UK public health departments

The relative time spent in different areas of work in public health departments in the UK was assessed by means of a postal questionnaire. Departments spend one third of their time on population health work, this being similar to the amount of time spent on planning health services. Having a planning department in the health authority did not affect the amount of time spent in any area of work. Having a greater number of consultants in the department was associated with a tendency to spend more time on population health and being involved in training was associated with spending less time on planning. Public health departments in the UK are the only part of the health service with responsibility for the broader aspects of public health. Whilst the tensions between medical care and the wider influences upon population health may represent a false dichotomy, public health professionals must maintain a central focus of their work on the wider influences upon population health if balance is to be maintained within the National Health Service.

Physical activity among older Filipino-American women

Filipino women (N = 530, mean age 63 years, predominantly low income) were recruited through various community based organizations and churches in Los Angeles County. All women were randomly invited to attend a single group session with a Filipino health educator to discuss breast and cervical cancer screening or the health benefits of exercise. At 3 months after the group session, the exercise assessment tool used in the National Health and Nutrition Examination Survey III was completed by 487 women (92 percent retention rate). This paper describes the pattern of physical activity among older Filipino-American women and a physical activity intervention specifically designed for this group.

Motivational intervention as applied to systems change: the case of dual diagnosis

The concept of motivational interviewing is based on helping individual clients build and sustain a commitment to reach and carry out a decision to change. In this paper, the motivational interviewing model is applied to systems change. Different stages of involvement and readiness to change are identified within systems which closely resemble those found in individuals. When applied to a system, we call this process "Motivational Intervention." In this paper, the motivational intervention model is applied to a psychiatric system of health care delivery where large numbers of psychiatric patients are found to also have substance use-related problems. Several Italian health districts invited the authors to present a series of lectures and workshops in order to facilitate the incorporation of substance user treatment into existing psychiatric services. Using the motivational intervention model to determine where the system was in the process of change, we then identified the tasks necessary to facilitate further change.

How well is the clinical importance of study results reported? An assessment of randomized controlled trials

BACKGROUND

The interpretation of the results of randomized controlled trials (RCTs) has traditionally emphasized statistical significance rather than clinical importance. Our aim was to assess the quality of reporting of factors related to clinical importance in a sample of published RCTs.

METHODS

A random sample of 27 (of a total of 266) RCTs published in 5 major medical journals over a 1-year period were reviewed by 4 independent reviewers for factors considered important in the interpretation of the clinical importance of study results: identification of a clearly defined primary outcome, reporting of the expected difference between groups used in the calculation of sample size (the delta value) and whether it was based on the minimal clinically important difference of the intervention, the statistical significance of the results, presentation of pertinent confidence intervals, and the authors' interpretation of the clinical importance of the results.

RESULTS

Twenty-two of 27 (81%) articles explicitly reported a single primary outcome. Of the 20 articles that included a sample size calculation, 18 (90%) reported a delta value. Two of the 18 (11%) articles explicitly stated that the delta value was chosen to reflect the minimal clinically important difference of the intervention. For the primary outcomes, confidence intervals surrounding the point estimates of the efficacy of the interventions were reported in 11 of 27 (41%) studies. The study results were interpreted from the perspective of clinical importance in 20 of 27 (74%) of the articles. Of these 20 reports, 5 (25%) provided justification for their clinical interpretation of the results.

INTERPRETATION

Authors of RCTs published in major general medical and internal medicine journals do not consistently provide their own interpretation of the clinical importance of their results, and they often do not provide sufficient information to allow readers to make their own interpretation.

Lifestyle changes in the management of osteoarthritis

Lifestyle changes are gaining increasing recognition in the management of osteoarthritis. In most guidelines advice on exercise and weight reduction is now given priority over pharmacological therapies. In view of the face validity, safety and cost-effectiveness of such measures this would seem appropriate. This chapter discusses the role of exercise therapy, weight reduction and footwear. The emphasis is on evidence for effectiveness, comparison of techniques available and maintenance of adherence with each lifestyle change. Because most of our knowledge surrounds management of knee osteoarthritis, this is the focus of our discussion, with reference being made to other sites as appropriate.

Nutrition and physical activity interventions to reduce cardiovascular disease risk in health care settings: a quantitative review with a focus on women

The authors conducted a quantitative literature review of the impact of 32 diet and physical activity (PA) interventions delivered in health care settings on cardiovascular disease risk factors. Intervention effects were relatively modest but statistically significant for PA, body mass index or weight, dietary fat, blood pressure, and total and low-density lipoprotein serum cholesterol. Intervention effects were generally larger for samples with a mean age >50 years and for studies with <6 months follow-up. Type of comparison group, type of intervention, and use of a behavior theory did not have a consistent impact on intervention effects. Few studies focused on persons of color, although the results from these studies are promising.

Advancing health promotion in Australian general practice

Health promotion activities, while having the potential to prevent disease and decrease the burden of ill health, often play a minor role in the health care offered by general practitioners. There are several identified barriers to the involvement of Australian general practitioners in health promotion. These include structural barriers and barriers within the practice setting, individual practitioner and patient factors, and difficulties in evaluating the outcomes of health promotion activities. This article explores the barriers to the engagement of Australian general practice with health promotion and reviews several recent initiatives that have the potential to increase the health promotion activities of general practitioners. These initiatives act at the level of the individual practitioner, the practice, and in the community. Despite the lack of a coordinated national approach, these strategies form an important development in general practice.

Assessing the association of walking with health services use and costs among socioeconomically disadvantaged older adults

BACKGROUND

The costs of physical inactivity are beginning to be recognized. Research to pinpoint these costs will provide needed information for researchers and policy-makers to develop cost-effective physical activity promotion programs. We present the association of walking with health services use and costs within a sample of 695 older, urban primary care patients.

METHODS

A survey provided most data, but utilization and cost data were obtained from a medical records system. Multivariate models were developed to assess the association of walking with health services use and costs, adjusting for sociodemographic characteristics, chronic disease, health status, and previous utilization.

RESULTS

Thirty-eight percent of respondents reported walking 0 minutes per week, 49% walked 1 to 119 minutes, and 13% walked 120 minutes or more. In the multivariate analyses, a report of walking 120 or more minutes was associated with a lower risk of emergency room visit and hospital stay in the subsequent year. No association was found between walking and primary care visits and total cost.

CONCLUSION

These analyses suggest an association of walking 120 minutes or more with decreased emergency room visits (OR = 0.5, P = 0.046) and hospital stays (OR = 0.6, P = 0.034). This suggests that physical activity promotion among socioeconomically disadvantaged older adults has the potential to provide cost savings. This will not be known, however, until physical activity can be promoted and maintained among these adults.

Prescribing exercise for cardiac patients: knowledge, practices, and needs of family physicians and specialists

PURPOSE

To determine the following about prescribing exercise for cardiac patients: physicians' present and needed knowledge; their present practices; barriers that hinder them; and perceived need for and content of a protocol for prescribing exercise.

METHODS

(1) Questionnaire mailed to 371 family physicians (FPs), 31 internists, and 25 cardiologists; and (2) four focus groups consisting of 25 FPs, 1 internist, and 3 cardiologists.

RESULTS

Questionnaire response rate was 45% (n = 192). Because responses were similar and the group was small, internists and cardiologists were combined as "specialists." Generally, questionnaire data agreed with focus group data, with the latter providing more detail. Family physicians perceived they know little about prescribing a specific exercise program while specialists perceived they know little about motivating patients to begin an exercise program. The method most frequently used by both physician groups to increase exercise is providing general advice. The main barriers to prescribing exercise were inadequate knowledge (FPs only), patient education materials, and community resources. Both groups rated highly the need for a protocol for prescribing exercise and indicated it should: (1) include identification of patient's stage of change; (2) include indications and contraindications for exercise; (3) provide guidelines for developing a specific exercise prescription; (4) contain patient education materials, and (5) be simple and short.

CONCLUSIONS

Family physicians perceive they know little about prescribing a specific exercise program for cardiac patients while specialists perceive they know little about motivating patients. Physicians rate highly the need for a protocol to help them prescribe exercise for cardiac patients.

Motivation and dietary self-care in adults with diabetes: are self-efficacy and autonomous self-regulation complementary or competing constructs?

This study examined constructs drawn from social-cognitive theory (A. Bandura, 1986) and self-determination theory (E. L. Deci & R. M. Ryan, 1985, 1991) in relation to dietary self-care and life satisfaction among 638 individuals with diabetes. A motivational model of diabetes dietary self-care was proposed, which postulates direct links between self-efficacy/autonomous self-regulation, and adherence/ life satisfaction. Structural equation modeling showed that both self-efficacy and autonomous self-regulation were associated with adherence (betas = .54 and .21, respectively) and with life satisfaction (betas = .15 and .34, respectively). Constraint analyses confirmed that self-efficacy was significantly more associated with adherence, whereas autonomous self-regulation was significantly more associated with life satisfaction. According to the model, interventions for dietary self-care and life satisfaction should focus on increasing self-efficacy and autonomous self-regulation.

Physical activity and cardiovascular risk factors: effect of advice from an exercise specialist in Australian general practice

OBJECTIVE

To determine whether provision of individualised physical activity advice by an exercise specialist in general practice is effective in modifying physical activity and cardiovascular risk factors in older adults.

DESIGN

Randomised controlled trial of individualised physical activity advice, reinforced at three and six months (intervention) versus no advice (control).

SETTING

Two general practices in Adelaide, South Australia, 1996.

PARTICIPANTS

299 adults aged 60 years or more who were healthy, sedentary and living in the community.

MAIN OUTCOME MEASURES

Changes to physical activity (frequency and duration of walking and vigorous exercise), selected cardiovascular risk factors (blood pressure, body weight, serum lipid levels) and quality of life over 12 months.

RESULTS

Self-reported physical activity increased over the 12 months in both groups (P < 0.001). The increase was greater for the intervention than the control group for all measures except time spent walking (P < 0.05). More intervention than control participants increased their intention to exercise (P < 0.001). Serum levels of total and low-density lipoprotein cholesterol and triglycerides fell significantly over the 12 months to a similar extent in the two groups. No other significant changes in cardiovascular risk factors were seen. Quality-of-life scores decreased over the 12 months. The decrease was significantly greater among intervention than control women, but not men, for emotional well-being (P = 0.02), physical well-being (P = 0.04) and social functioning (P = 0.04).

DISCUSSION

Provision of general practice-based physical activity advice reinforced three-monthly produced a sustained increase in self-reported physical activity. However, there were no associated changes in clinical measures of cardiovascular risk factors and minimal changes in quality-of-life measures.