Predictors of older primary care patients' participation in a submaximal exercise test and a supervised, low-impact exercise class

Moving an exercise referral scheme to remote delivery during the Covid-19 pandemic: an observational study examining the impact on uptake, adherence, and costs

BACKGROUND

Exercise Referral Schemes (ERSs) have been implemented across Western nations to stimulate an increase in adult physical activity but evidence of their effectiveness and cost-effectiveness is equivocal. Poor ERS uptake and adherence can have a negative impact on effectiveness and cost-effectiveness and, if patterned by socio-demographic factors, can also introduce or widen health inequalities. Different modes of ERS delivery have the potential to reduce costs and enhance uptake and adherence. The primary aim of this study was to examine the effect of different programmes of ERS delivery on scheme uptake and adherence. Secondary aims were to examine the effect of socio-demographic factors on scheme uptake and adherence, and the impact of delivery mode on the expected resource and corresponding costs of delivering core parts of the programme.

METHODS

This was an observational cohort study with cost analysis. Routine monitoring data covering a three-year period (2019-2021) from one large UK ERS (number of patients = 28,917) were analysed. During this period three different programmes of delivery were operated in succession: standard (all sessions delivered face-to-face at a designated physical location), hybrid (sessions initially delivered face-to-face and then switched to remote delivery in response to the Covid-19 pandemic), and modified (sessions delivered face-to-face, remotely, or a combination of the two, as determined on a case-by-case basis according to Covid-19 risk and personal preferences). Multi-level binary logistic and linear regression were performed to examine the effect of programme of delivery and socio-demographic characteristics on uptake and adherence. Cost data were sourced from regional-level coordinators and through NERS audits supplied by national-level NERS managers and summarised using descriptive statistics.

RESULTS

There was no effect of programme of delivery on scheme uptake. In comparison to those on the standard programme (who attended a mean of 23.1 exercise sessions) those on the modified programme had higher adherence (mean attendance of 25.7 sessions) while those on the hybrid programme had lower adherence (mean attendance of 19.4 sessions). Being older, or coming from an area of lower deprivation, increased the likelihood of uptake and adherence. Being female increased the chance of uptake but was associated with lower adherence. Patients referred to the programme from secondary care were more likely to take up the programme than those referred from primary care for prevention purposes, however their attendance at exercise sessions was lower. The estimated cost per person for face-to-face delivery of a typical 16-week cycle of the scheme was £65.42. The same cycle of the scheme delivered virtually (outside of a pandemic context) was estimated to cost £201.71 per person.

CONCLUSIONS

This study contributes new evidence concerning the effect of programme of delivery on ERS uptake and adherence and strengthens existing evidence concerning the effect of socio-economic factors. The findings direct the attention of ERS providers towards specific patient sub-groups who, if inequalities are to be addressed, require additional intervention to support uptake and adherence. At a time when providers may be considering alternative programmes of delivery, these findings challenge expectations that implementing virtual delivery will necessarily lead to cost savings.

Socioecological Factors Associated with an Urban Exercise Prescription Program for Under-Resourced Women: A Mixed Methods Community-Engaged Research Project

One strategy to promote physical activity (PA) is for health care providers to give exercise prescriptions (ExRx) that refer to community-based facilities. However, facilitators and barriers specific to urban programs in the US for under-resourced women are unknown. Thus the purpose of this formative research was to explore ExRx barriers and facilitators specific to US under-resourced women to inform future intervention targets and strategies. This mixed-methods community-engaged research was conducted in partnership with an urban women's only wellness center that exchanged ExRx for free access (1-3 months). Qualitative semi-structured interviews and validated quantitative questionnaires (SF-12, International Physical Activity Questionnaire, Physical Activity Self-Efficacy, Physical Activity Stage of Change, and Barriers to Physical Activity, Social Support for Exercise, and Confusion, Hubbub, and Order Scale) were administered by phone and guided by the socio-ecological model. ExRx utilization was defined as number visits/week divided by membership duration. Means and percentages were compared between ≥1 visit/week vs. <1 visit/week with t-tests and chi-square, respectively. Women (n = 30) were 74% Black, 21-78 years of age, 50% had ≤ high school diploma, and 69% had household incomes ≤45,000/year. Women with ≥1 visit/week (n = 10; 33%) reported more education and higher daily activity, motivation, number of family CVD risk factors and family history of dyslipidemia compared with <1 visit/week. Facilitators among women with ≥1 visit/week were "readiness" and "right timing" for ExRx utilization. Barriers among women with <1 visit/week (n = 20; 67%) were "mismatched expectations" and "competing priorities". Common themes among all women were "sense of community" and "ease of location". ExRx utilization at an US urban wellness center may be dependent on a combination of multi-level factors including motivation, confidence, peer support, location and ease of access in under-sourced women. Additional resources may be needed to address mental and/or physical health status in additional to physical activity specific programming.

Thai Older People's Willingness (Intention) to Participate in a Care Prevention, Community Group Exercise Program: An Assessment before Implementing an Intervention Trial in Chiang Mai, Northern Thailand

BACKGROUND

Sustainability of a current family-based long-term care model in Thailand has been challenged by demographic aging, and the rising burden of non-communicable diseases and age-related morbidities. In order to overcome these challenges, a community-integrated intermediary care (CIIC) service model, including functional training as one of the interventions, was introduced. To increase program uptake and adherence, it is vital to understand the facilitators and barriers for joining this group exercise. Therefore, we aimed to explore the determinants of older adults' willingness to participate in it.

METHODS

A total of 1509 participants from an intervention arm of a cluster randomized trial were interviewed with a structured questionnaire. A descriptive analysis and binary logistic regression were applied.

RESULTS

More than half of participants (51.4%) were willing to join community-based care prevention, functional training exercise program. Significant associated motivators were being of younger age, female, married, working seniors, original community residents, having (regular and irregular) exercise habits, history of a fall in the last six months, needs for walking aids and secondary caregivers.

CONCLUSION

Our findings highlighted both personal and social factors motivated old people to access health promotion activities. It might help design or implement effective programs to promote healthy aging among community-dwelling seniors in Thailand. This research is analysis of baseline results from a Community Integrated Intermediary Care project. TCTR20190412004.

Patterning in Patient Referral to and Uptake of a National Exercise Referral Scheme (NERS) in Wales From 2008 to 2017: A Data Linkage Study

Exercise referral schemes have shown small but positive impacts in randomized controlled trials (RCTs). Less is known about the long-term reach of scaled up schemes following a RCT. A RCT of the National Exercise Referral Scheme (NERS) in Wales was completed in 2010, and the scheme scaled up across Wales. In this study, using a retrospective data linkage design, anonymized NERS data were linked to routine health records for referrals between 2008 and 2017. Rates of referral and uptake were modelled across years and a multilevel logistic regression model examined predictors of uptake. In total, 83,598 patients have been referred to the scheme and 67.31% of eligible patients took up NERS. Older adults and referrals for a musculoskeletal or level four condition were more likely to take up NERS. Males, mental health referrals, non-GP referrals and those in the most deprived groupings were less likely to take up NERS. Trends revealed an overall decrease over time in referrals and uptake rates among the most deprived grouping relative to those in the least deprived group. Findings indicate a widening of inequality in referral and uptake following positive RCT findings, both in terms of patient socioeconomic status and referrals for mental health.

One-year effects of a group-based lifestyle intervention in adults with type 2 diabetes: A randomized encouragement trial

AIMS

To estimate the real-world effects of offering a group-based lifestyle intervention (GLI) to adults with diabetes.

METHODS

This randomized encouragement trial included adult primary care patients in metropolitan Chicago with type 2 diabetes and body mass index ≥24 kg/m². Participants were randomized to standard care (brief dietary and lifestyle counseling) or standard care plus being encouraged, but not required, to participate in a free-of-charge GLI offered by the YMCA. The GLI was a group-based adaptation of the Look AHEAD lifestyle intervention.

RESULTS

Of 331 participants, 167 were randomized to standard care and 164 to the GLI encouragement arm. About one third of participants were non-Hispanic White (34.4%). In the GLI arm, 75 (45.7%) attended ≥1 GLI visits. In the primary intention-to-treat analysis, the effect of GLI encouragement was 0.95% weight loss at six months (95% confidence interval [CI], 0.13-1.77%; P = 0.02), and 1.20% weight loss at 12 months (95% CI, 0.05-2.36%; P = 0.04). At 12 months, there was a 0.30% (3.3 mmol/mol) reduction in hemoglobin A1c, but this result did not achieve statistical significance (P = 0.054). In instrumental variable analysis estimating effects among the subgroup of participants who attended any GLI visits, the effect of GLI attendance was 2.30% weight loss at six months (95% CI, 0.30-4.30%; P = 0.02), and 2.07% weight loss at 12 months (95% CI, 0.25-3.88%; P = 0.02). We detected no significant blood pressure or cholesterol effects.

CONCLUSIONS

Among adults with type 2 diabetes, a group-based lifestyle intervention in a community-based setting achieved modest weight loss at 6 and 12 months.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01435603.

A systematic review and economic evaluation of exercise referral schemes in primary care: a short report

BACKGROUND

It is estimated that only 39% of men and 29% of women in England achieve the levels of physical activity that are recommended to protect health and prevent disease. One approach to addressing this problem has been the development of exercise referral schemes (ERSs), in which health professionals refer patients to external exercise providers. These schemes have been widely rolled out across the UK despite concerns that they may not produce sustained changes in levels of physical activity and, therefore, may not be cost-effective interventions. The evidence to determine clinical effectiveness and cost-effectiveness was evaluated in 2009. This review seeks to update this earlier work by incorporating new evidence and re-examining the cost-effectiveness.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of ERSs compared with usual care.

DESIGN

Exhaustive searches of relevant electronic databases and journals were undertaken to identify new studies evaluating ERSs using a randomised controlled trial (RCT) design. RCTs that incorporated a qualitative evaluation of the intervention were identified in order to explore the barriers and facilitators to the uptake of and adherence to ERSs. Data were extracted using a previously designed tool and study quality assessed for potential bias. Where data could be pooled, meta-analyses were carried out. Qualitative analysis was also undertaken using a thematic approach. The cost-effectiveness was evaluated using a Markov structure which estimated the likelihood of becoming physically active and the subsequent risk reduction on coronary heart disease (CHD), stroke and type 2 diabetes mellitus. The model adopts a lifetime horizon, and a NHS and Personal Social Services perspective was taken with discounting at 1.5% for both costs and benefits.

RESULTS

The search identified one new RCT and one new qualitative study. The new data were pooled with existing data from the 2011 review by Pavey et al. [Pavey TG, Anokye N, Taylor AH, Trueman P, Moxham T, Fox KR, et al. The clinical effectiveness and cost-effectiveness of exercise referral schemes: a systematic review and economic evaluation. Health Technol Assess 2011;15(44)] to give a total of eight studies with 5190 participants. The proportion of individuals achieving 90-150 minutes of at least moderate-intensity activity per week at 6-12 months' follow-up was greater for ERSs than usual care (relative risk 1.12; 95% confidence interval 1.04 to 1.20). Older patients and those referred for CHD risk factors appeared to be more likely than others to increase their levels of physical activity. Qualitative evidence suggests that interventions enabling the development of social support networks are beneficial in promoting uptake and adherence. Exercise referral gained 0.003 quality-adjusted life-years (QALYs) at an additional cost of £225 per person. The estimated mean incremental cost-effectiveness ratio (ICER) in the probabilistic sensitivity analysis was £76,276. In the univariate sensitivity analysis the results were very sensitive (ICERs ranged from < £30,000 to > £100,000) to changes in the effect of ERSs on physical activity uptake and the duration of the protective effects and the direct health-related quality-of-life gains attributable to physical activity.

CONCLUSIONS

Exercise referral schemes result in a small improvement in the number of people who increase their levels of physical activity. The cost-effectiveness analysis indicates that the ICER for ERSs compared with usual care is around £76,000 per QALY, although the cost-effectiveness of ERSs is subject to considerable uncertainty.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013005200.

FUNDING

National Institute for Health Research Health Technology Assessment programme.

Utilizing an integrated infrastructure for outcomes research: a systematic review

OBJECTIVE

To explore the ability of an integrated health information infrastructure to support outcomes research.

METHODS

A systematic review of articles published from 1983 to 2012 by Regenstrief Institute investigators using data from an integrated electronic health record infrastructure involving multiple provider organisations was performed. Articles were independently assessed and classified by study design, disease and other metadata including bibliometrics.

RESULTS

A total of 190 articles were identified. Diseases included cognitive, (16) cardiovascular, (16) infectious, (15) chronic illness (14) and cancer (12). Publications grew steadily (26 in the first decade vs. 100 in the last) as did the number of investigators (from 15 in 1983 to 62 in 2012). The proportion of articles involving non-Regenstrief authors also expanded from 54% in the first decade to 72% in the last decade. During this period, the infrastructure grew from a single health system into a health information exchange network covering more than 6 million patients. Analysis of journal and article metrics reveals high impact for clinical trials and comparative effectiveness research studies that utilised data available in the integrated infrastructure.

DISCUSSION

Integrated information infrastructures support growth in high quality observational studies and diverse collaboration consistent with the goals for the learning health system. More recent publications demonstrate growing external collaborations facilitated by greater access to the infrastructure and improved opportunities to study broader disease and health outcomes.

CONCLUSIONS

Integrated information infrastructures can stimulate learning from electronic data captured during routine clinical care but require time and collaboration to reach full potential.

Design and participant characteristics for a randomized effectiveness trial of an intensive lifestyle intervention to reduce cardiovascular risk in adults with type 2 diabetes: The I-D-HEALTH study

Intervening in Diabetes with Healthy Eating, Activity and Linkages To Healthcare (I-D-HEALTH) is a community-based randomized trial evaluating the effectiveness of a group-based adaption of the Look AHEAD intensive lifestyle intervention. Most potentially eligible patients were identified through electronic medical record queries or referral to a diabetes resource hub. Trial enrollees had a usual source of primary care, elevated body mass index (BMI) and type 2 diabetes. I-D-HEALTH participants were randomized to either standard care alone or standard care plus free-of-charge access to a group-based lifestyle intervention (GLI) offered by the YMCA. GLI participation was encouraged, but not required, for the latter group. The primary outcome is percent weight change over 6, 12 and 24months. Secondary outcomes include direct intervention costs and direct medical and non-medical expenditures, as well as changes in systolic blood pressure, hemoglobin A1c and cholesterol. Among 331 I-D-HEALTH participants, 167 were randomized to standard care and 164 to GLI. The mean age (±standard deviation) in each group was 57.1years (±12.2) and 57.6years (±10.5), respectively. Mean BMI was 34.9kg/m(2) (±7.3) among standard care participants and 36.2kg/m(2) (±7.8) among GLI participants. In both groups, approximately one third of participants were non-Hispanic Whites. We detected no significant differences between groups in mean systolic blood pressure, hemoglobin A1c or total cholesterol (P >0.05 for all characteristics above). The I-D-HEALTH study enrolled a diverse sample of adults with diabetes and offers a unique opportunity to evaluate the effectiveness of offering a community-based intensive lifestyle intervention.

The feasibility of a physical activity referral network for pediatric obesity

BACKGROUND

Pediatricians cite a lack of physical activity referral (PAR) opportunities as a major barrier to treating obesity. However, no literature exists on PARs for youth in the clinical setting. This study explores the feasibility of implementing PARs in a pediatric obesity clinic.

METHODS

Patients ages 6-18 years in an obesity clinic from July 2010 to October 2011 were referred to PARs in their community. Researchers confirmed enrollment and participation in activities by follow-up phone calls.

RESULTS

Of 130 eligible youth, 102 (78%) agreed to be referred to a physical activity program; 45 (35%) enrolled and 35 (27%) reported actually participating in an activity, for an average of 1.4 hours per week. Youth participated in 9 of 69 available activity programs included in the PAR network. Patient characteristics at baseline did not predict participation in an activity. Youth referred to organizations that contacted interested families were 5 times as likely to enroll in activities as youth referred to organizations that did not contact families (p < 0.001).

CONCLUSION

Although only 27% of eligible youth participated in an activity through the PAR network, exposing 1 in 4 obese youth to 1.4 hours of physical activity weekly could have a significant public health impact. These results suggest that PAR networks for overweight and obese youth should focus on organizations that have the infrastructure to contact youth and their families, and that a small number of physical activity programs could form the basis for launching PAR networks.

Older black women's experiences initiating and maintaining physical activity: implications for theory and practice

Using a semistructured discussion guide, the authors conducted 15 interviews with physically active older black women living in the eastern U.S. to examine what contributed to their physical activity initiation and maintenance. They used thematic analysis to organize content and constant-comparison methods to compare themes between participants. Participants initiated physical activity when a cue to action, such as weight gain or a medical issue, triggered a perceived need to exercise. When participants initiated physical activity, they experienced immediate unexpected benefits such as improved energy. They reported continuing activity because of these initial benefits. After continued physical activity over time, participants experienced the health benefits they originally hoped to achieve. Most participants also mentioned continuing physical activity because it is "me time." All participants reported needing to modify their physical activity routine at some point. Having a regular, yet adaptable, routine and planning skills helped participants maintain physical activity. These findings contribute to the refinement of theory and might be useful for professionals promoting physical activity among older black women.

A Systematic Review of Perceived Barriers and Motivators to Physical Activity after Stroke

Background and purpose

Physical fitness is impaired after stroke, may contribute to disability, yet is amenable to improvement through regular physical activity. To facilitate uptake and maintenance of physical activity, it is essential to understand stroke survivors' perceived barriers and motivators. Therefore, we undertook a systematic review of perceived barriers and motivators to physical activity after stroke.

Methods

Electronic searches of EMBASE, Medline, CINAHL, and PsychInfo were performed. We included peer-reviewed journal articles, in English, between 1 January 1966 and 30 August 2010 reporting stroke survivors' perceived barriers and motivators to physical activity.

Results

Searches identified 73 807 citations of which 57 full articles were retrieved. Six articles were included, providing data on 174 stroke survivors (range 10 to 83 per article). Two reported barriers and motivators, two reported only motivators, and two reported only barriers. Five were qualitative articles and one was quantitative. The most commonly reported barriers were lack of motivation, environmental factors (e.g. transport), health concerns, and stroke impairments. The most commonly reported motivators were social support and the need to be able to perform daily tasks.

Conclusion

This review has furthered our understanding of the perceived barriers and motivators to physical activity after a stroke. This review will enable the development of tailored interventions to target barriers, while building upon perceived motivators to increase and maintain stroke survivors' physical activity.

Exercise adoption among older, low-income women at risk for cardiovascular disease

Using an expanded Social Cognitive Theory (SCT) model, we hypothesized that self-efficacy, outcome expectations, and exercise self-definition would predict exercise adoption. This secondary analysis examined data from a prospective single-group study of low-income women who received a physician screen and referral to a community-based, free exercise program. The sample included 190 older, low-income women with a mean age of 64 years, the majority of whom were African American (66%) and had at least one cardiovascular risk factor (92%). Baseline values of self-efficacy, outcome expectations, and exercise self-definition were measured using instruments developed for the study. Exercise adoption was defined as the number of exercise sessions completed over 8 weeks. Our hypothesis was tested using hierarchical multiple regression. The mean number of exercise sessions completed over the 8-week period was 5.7 out of a recommended 24. Value of Exercise scores, a subscale of the Exercise Self-Definition scale, predicted exercise adoption. Self-efficacy and outcome expectations were not predictive. The significance of Value of Exercise scores reinforces the importance of expanding SCT with additional variables such as exercise self-definition. Future work should emphasize the social and environmental factors that form an important part of SCT.

Why don't you exercise? Development of the Amotivation Toward Exercise Scale among older inactive individuals

This article reports on the development and initial validation of the Amotivation Toward Exercise Scale (ATES), which reflects a taxonomy of older adults' reasons to refrain from exercise. Drawing on work by Pelletier, Dion, Tuson, and Green-Demers (1999) and Legault, Green-Demers, and Pelletier (2006), these dimensions were the outcome beliefs, capacity beliefs, effort beliefs, and value amotivation beliefs toward exercise. The results supported a 4-factor correlated model that fit the data better than either a unidimensional model or a 4-factor uncorrelated model or a hierarchical model with strong internal reliability for all the subscales. Evidence also emerged for the discriminant validity of the subscale scores. Furthermore, the predictive validity of the subscale scores was supported, and satisfactory measurement invariance was demonstrated across the calibration and validation samples, supporting the generalizability of the scale's measurement properties.

Impact of provider self-management education, patient self-efficacy, and health status on patient adherence in heart failure in a Veterans Administration population

To address the need for more information on predictors of adherence to heart failure (HF) self-management regimens, this study analyzed surveys completed by 259 HF patients receiving care at 2 Veterans Affairs hospitals in 2003. Linear multivariable regression models were used to examine general health status, HF-specific health status (Kansas City Cardiomyopathy Questionnaire) self-management education, and self-efficacy as predictors of self-reported adherence to salt intake and exercise regimens. Self-management education was provided most often for salt restriction (87%) followed by exercise (78%). In multivariable regression analyses, education about salt restriction (P=.01), weight reduction (P=.0004), self-efficacy (P=.03), and health status (P=.003) were significantly associated with patient-reported adherence to salt restriction. In a similar model, self-efficacy (P=.006) and health status (P< or = .0001), but not exercise education, were significantly associated with patient-reported exercise adherence. Findings suggest that provider interventions may lead to improved adherence with HF self-management and thus improvements in patients' health.

Effectiveness of exercise-referral schemes to promote physical activity in adults: systematic review

BACKGROUND

Despite the health benefits of physical activity, most adults do not take the recommended amount of exercise.

AIM

To assess whether exercise-referral schemes are effective in improving exercise participation in sedentary adults.

DESIGN OF STUDY

Systematic review.

METHOD

Studies were identified by searching MEDLINE, CINAHL, EMBASE, AMED, PsycINFO, SPORTDiscus, The Cochrane Library and SIGLE until March 2007. Randomised controlled trials (RCTs), observational studies, process evaluations and qualitative studies of exercise-referral schemes, defined as referral by a primary care clinician to a programme that encouraged physical activity or exercise were included. RCT results were combined in a meta-analysis where there was sufficient homogeneity.

RESULTS

Eighteen studies were included in the review. These comprised six RCTs, one non-randomised controlled study, four observational studies, six process evaluations and one qualitative study. In addition, two of the RCTs and two of the process evaluations incorporated a qualitative component. Results from five RCTs were combined in a meta-analysis. There was a statistically significant increase in the numbers of participants doing moderate exercise with a combined relative risk of 1.20 (95% confidence intervals = 1.06 to 1.35). This means that 17 sedentary adults would need to be referred for one to become moderately active. This small effect may be at least partly due to poor rates of uptake and adherence to the exercise schemes.

CONCLUSION

Exercise-referral schemes have a small effect on increasing physical activity in sedentary people. The key challenge, if future exercise-referral schemes are to be commissioned by the NHS, is to increase uptake and improve adherence by addressing the barriers described in these studies.

The effectiveness of a health promotion programme for women in southern Taiwan

The purpose of this study was to assess the effectiveness of an 8 week aerobic exercise class for women on changes in their physical activity behaviour. This was a descriptive, retrospective and comparison study. Because the data were collected after an 8 week aerobic exercise class, there were two groups of subjects. Subjects in the exercise group had attended exercise classes, but subjects in the control group had not. Results showed statistically significant differences between the two groups in the frequency/week of moderately intense exercise-related activities, caloric expenditure/week in all exercise-related activities and caloric expenditure/week in moderately intense exercise-related activities. However, there was no statistically significant difference in the frequency/week of all exercise-related activities. The result that women in the exercise group practised physical activities more than women in the control group might be related to their high exercise self-efficacy expectations.

Outcome expectations and physical activity participation in two samples of older women

Outcome expectations have received little study in physical activity (PA) research. This study examined whether initial outcome expectations and their achievement at 6 months (i.e. outcome realizations) predicted subsequent PA participation (7-12 months) in 118 older women. Initial outcome expectations were not associated with PA participation. Outcome realizations at 6 months, however, predicted subsequent PA participation (p < .05). Women with high expectations but low attainment had the lowest subsequent participation rates. Women with high attainment, regardless of expectations, had the highest rates. Findings replicate and extend an earlier study and argue for a more dynamic conceptualization of outcome expectations.

Attitudes and practices of physicians and nurses regarding physical activity promotion in the Catalan primary health-care system

BACKGROUND

In Catalonia a high percentage of the population remains inactive. General practices are an ideal setting to advise on physical activity (PA). However, there is a lack of evidence regarding practices, barriers and predictors of such promotion in the Catalan primary health-care system. This study set out to establish descriptive baseline data for PA promotion in Catalan general practices, and to explore the experiences of doctors/nurses in promoting PA in their day-to-day professional lives.

METHODS

A mixed-method approach was adopted. A survey was conducted with 245 physicians/nurses (58% response rate). Subsequently, focus groups (n = 5) and semi-structured interviews (n = 7) were conducted with 18 physicians and 15 nurses. After coding for important themes, the final interpretation was confirmed by contributors.

RESULTS

Eighty-eight percent of physicians/nurses promoted PA at least infrequently. However, work conditions were perceived as unfavourable, with the main barriers being lack of (i) time, (ii) training and (iii) protocols. Qualitative data showed that PA promotion was opportunistic, focused on selected patients, used generalized messages and was highly dependent on personal interests. Regular promotion was encouraged by direct experiences of the benefits of regular exercising, knowing patients well, being supported by medical colleagues and creating links with other community institutions. PA promotion was especially hindered by seeing PA promotion as a secondary task, and patients ignoring recommendations.

CONCLUSIONS

PA promotion in Catalonia remains to be integrated into practice consultations. Therefore, strategies should be developed within public health. Using a mixed-method approach provided a broader range of evidence than most studies, which rely on quantitative methods.

Health promotion referrals in an urban clinic: removing financial barriers influences physician but not patient behavior

PURPOSE

This study describes the prevalence and characteristics of physician health promotion referrals and patient adherence to referrals in a community-based primary care clinic and associated wellness facility. The role of reimbursement for attendance to the wellness facility was specifically examined.

DESIGN

Retrospective cohort study.

SETTING

The Church Health Center of Memphis, Tennessee: a low-income urban clinic and its affiliated wellness center.

SUBJECTS

Patients were primarily African-American, lower-income, urban residents of Shelby County, Tennessee.

MEASURES

All study data came from existing medical clinic and wellness facility records of utilization, patient history, and diagnoses.

RESULTS

Of 6321 clinic patients, 16.7% (n = 1069) received a provider health promotion referral. Logistic regression analyses identified that physician referral was related to patient factors of access to free wellness-facility membership, employment status, receiving a behavior-related diagnosis, and being African-American and female. Of patients receiving a referral 17.2% (n = 184) adhered to this advice and visited the wellness facility. New patients were more likely to adhere to a referral than established patients.

CONCLUSION

Demographic, financial, and patient characteristics influenced whether health behavior change referrals were made by primary care physicians in a community clinic. Removing financial barriers did not influence patient adherence, but new patients were more likely to follow the recommendation than those previously seen at the clinic.

Motivational factors influencing older adults diagnosed with knee osteoarthritis to join and maintain an exercise program

In order to provide successful interventions to increase physical activity among inactive older adults, it is imperative to understand motivational factors influencing exercise. The authors present data from 191 (baseline) and 125 (12-month) community-dwelling men and women with mean ages of 68.71 (7.47) and 67.55 (7.55) years, respectively, from a strength-training trial. Approximately 53% had diagnosed knee osteoarthritis. Using a Likert scale, participants self-reported their degree of motivation from personal, social, and environmental factors. Using multivariate analyses, the authors evaluated demographic and clinical correlates of motivational factors to join and continue with exercise. The following results were reported: Knee osteoarthritis was positively related to motivation from an organized exercise opportunity and from efficacy/outcome expectations, and knee pain was positively related to motivation from social support and experience with the exercise task. Understanding these motivators might help in targeting recruitment efforts and interventions designed to increase physical activity in older adults with lower extremity arthritis.

A review of the outcome expectancy construct in physical activity research

BACKGROUND

Outcome expectancy is a central construct in social cognitive models of health behavior widely used as frameworks for physical activity research.

PURPOSE

This article provides a review of the outcome expectancy construct and its application to research on physical activity.

METHODS

Theoretical articles describing definitions and placement of outcome expectancy within social cognitive models, as well as empirical research on outcome expectancy and physical activity, were reviewed.

RESULTS

Self-efficacy theory, the transtheoretical model, the theory of planned behavior, and protection motivation theory differ in their labeling and conceptualization of outcome expectancy but unanimously include expected outcomes of behavior. Preliminary empirical investigation of the role of outcome expectancy in understanding physical activity has yielded mixed results. Positive outcome expectancy appears to be more predictive of physical activity in older adults than in young to middle-aged adults, and personal barriers appear to be the most predictive subtype of negative outcome expectancy. In addition, a small number of studies indicate relations between outcome expectancy and other theoretical variables, including behavioral intention, stage of change, and self-efficacy.

CONCLUSIONS

Further research on the role of outcome expectancy is necessary to design effective physical activity interventions. New directions in outcome expectancy research could involve (a) expanding the conceptualization of outcome expectancy to include expected outcomes of sedentary behavior and affective responses to physical activity, (b) further examination of potential moderators of the relation between outcome expectancy and physical activity (such as outcome value and outcome proximity), (c) distinguishing between the role of outcome expectancy in behavior onset versus behavior maintenance, (d) examining outcome expectancy as a mechanism of change in environmental intervention approaches, and (e) further analysis of interrelations between outcome expectancy and other social cognitive variables.

Relationships between exercise self-definitions and exercise participation among urban women in primary care

Exercising prevents the development of coronary artery disease and reduces the incidence of cardiovascular risk factors; however, the mechanisms that underlie participation in an exercise program are not well understood. On the basis of theories of the self, we hypothesized that exercise self-definitions would be significantly related to exercise participation and that such definitions would increase over time. The study sample consisted of 192 middle-aged to older women who were leading a mostly sedentary life and the majority had at least one cardiovascular risk factor. Exercise participation was defined as the number of exercise sessions completed at 8 and 24 weeks. We found an interesting pattern of significant relationships between exercise definitions and exercise participation. Six-month scores were significantly higher than baseline scores, suggesting that exercise self-definitions strengthened over time. If this result is found to be supported in future studies, nurses may want to consider assessing self-definitions when helping patients initiate and maintain an exercise program.

The Effects of Health and Environment on Exercise-Class Participation in Older, Urban Women

This research investigated the effects of health and environmental factors on the dropout and intermittent nonattendance of an exercise program designed specifically for older, female, primary-care patients living in the inner city. Class-attendance records (n = 21,538) from a cohort 110 women were analyzed. Women who dropped out early had poorer perceived health and were more likely to report pain as an exercise barrier at baseline. Those who lived in a census tract where a larger percentage of workers walk to work were less likely to drop out early. Intermittent nonattendance was associated with adverse weather conditions including heat index above 90 degrees F, wind-chill index below 20 degrees F, overcast sky, and snow. Better attendance was associated with greater atmospheric pressure, as well as lower number of sunlight hours per day. This research highlights the need to better understand environmental barriers when promoting physical activities in older women.