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Exercise Is Medicine for Underserved and Vulnerable Populations: Factors Influencing Implementation

Vermeesch, Amber L.1; Bustamante, Eduardo E.2; Coleman, Nailah3; Goldsby, TaShauna4; Hasson, Rebecca E.5; Hooker, Steven P.6; Marquez, David X.2; Conroy, Molly B.7

Author Information
Translational Journal of the ACSM: Spring 2022 - Volume 7 - Issue 2 - e000196
doi: 10.1249/TJX.0000000000000196
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Abstract

INTRODUCTION

To help address the pervasive problem of inadequate physical activity and related health problems, the American College of Sports Medicine (ACSM) and the American Medical Association co-launched Exercise Is Medicine® (EIM®) in the United States in 2007 (1–4). EIM® began as a population health initiative with a vision for healthcare providers to assess physical activity at every visit, determine whether a patient is meeting physical activity guidelines, and provide brief counseling and/or a referral to either healthcare or community-based resources. The referral may include an ACSM-credentialed exercise specialist as part of the treatment team. Of note, the ACSM credential matches with the person’s chronic disease. The ACSM designed EIM® to bring together three key groups of stakeholders to reach this goal: health care providers, exercise professionals, and the community (3,5).

Historically, the United States has defined access to health care by the presence or lack of health insurance. Underserved populations have limited access to health insurance, traditional medical care, healthcare facilities, and/or exercise facilities (6). Vulnerable populations may have access to such resources but are more likely to experience higher levels of inequity, bias, or discrimination based on their identity. Lack of access or inequitable access to any of these healthcare resources negatively affects EIM® implementation. For example, some health insurance plans may not allow for routine preventive services, such as an office visit where EIM® counseling might occur, or may require copayments for such services that can make them cost-prohibitive for members of underserved and vulnerable populations (UVP). In addition, EIM® counseling requires a provider (primary care or other) who has either awareness of the EIM® initiative or other resources to provide physical activity counseling. For EIM® to maximize the impact on UVP that have the most to gain from its effective and successful implementation, it must consider and address these populations’ specific needs and barriers and integrate appropriate dissemination and implementation frameworks within the current healthcare policy.

The ACSM Underserved and Community Health Committee defines UVP to include the following groups: racial and ethnic minorities, individuals with disability, those from rural and inner-city areas, elderly and pediatric populations, undocumented immigrants and political refugees, the uninsured/underinsured, those with low income, individuals with chronic medical conditions, non-English-speaking populations, and those with limited health literacy. In the United States, there is a long history of systemic racism, sexism, ableism, xenophobia, and social injustice disproportionately involving UVP. With reference to systemic racism, there are multiple infamous historical examples in medical research including the United States Public Health Service Syphilis Study at Tuskegee (1932–1972) and the case of Henrietta Lacks (1951) (7,8). Given that this article focuses more on a contemporary initiative in the clinical setting versus the research setting, we feel that systemic racism and social injustices highlighted during the COVID-19 pandemic are also relevant to this context. For example, Hasson et al. (9) found elevated significant associations between structural racism, as measured by such means as segregation and incarceration rates, and higher rates of COVID-19 cases and deaths. These examples and more highlight racism as a public health crisis that directly impacts the health of UVP.

The rationale for this article is to describe challenges in implementing EIM® in UVP, discuss potential solutions to these challenges, and share lessons learned from a decade of work in this area. We describe individual, relationship, community, and societal levels required for successful dissemination and implementation of EIM® in UVP. In addition, we discuss dissemination and implementation frameworks that have the potential to improve the public health impact of EIM® in UVP. We conclude with a brief discussion of the implications of health policy changes, especially those related to the Affordable Care Act (ACA), for EIM® in UVP.

METHODS

The ACSM chartered committees to work within the broader framework of EIM® to represent diverse population health needs. The mission of the ACSM Underserved and Community Health Committee is to ensure that the needs of UVP are represented in the planning, implementation, and evaluation of EIM®. This committee meets on a quarterly basis to discuss topics such as culturally appropriate training for EIM® professionals, translation of EIM® materials into Spanish, and use of representative images and language in EIM® materials. A focus of the committee is to ensure that content related to UVP is presented at the annual World Congress on Exercise Is Medicine, held in conjunction with the ACSM Annual Meeting. From 2012 to 2018, the Underserved and Community Health Committee presented four symposia and tutorial lectures related to EIM® in UVP. Hereinafter, we consolidate the findings of these presentations and provide an analysis of shifts in the environment due to the COVID-19 pandemic and shifts in healthcare policies related to the ACA. These symposia included both Underserved and Community Health Committee members and other national experts in relevant fields of health disparities, health policy, implementation science, and health care delivery. Symposia highlights and relevant updates were collated by a writing group of committee members for this article and organized through applying the Socioecological Model (SEM). The SEM was adapted by the Centers for Disease Control and Prevention to inform health promotion programs and uses a four-level model influencing health grounded in social ecological theory and based on seminal work by Bronfenbrenner (10). The levels of SEM used by the Centers for Disease Control and Prevention—individual, relationship, community, and societal—are used to organize both barriers and potential solutions to EIM® to UVP (11) and are shown along with examples of each level in Fig. 1.

F1
Figure 1:
Examples of factors influencing EIM® adoption in underserved and vulnerable populations at different levels of the Socioecological Model.

RESULTS

Table 1 provides an overview of barriers and potential solutions to EIM® implementation for various UVP groups determined by the Underserved and Community Health Committee; some of these groups will be discussed in more detail later in the article. The authors do not intend Table 1 populations to be a comprehensive list. The subsequent sections describe examples of factors influencing EIM® implementation in UVP at the individual, relationship, community, and societal levels.

TABLE 1 - Examples of UVP, Barriers, and Potential Solutions.
UVP Implementation Barrier Potential Solution/Method for Implementation
Racial and ethnic minorities Discrimination (institutional/interpersonal), lack of access to medical and fitness resources, medical mistrust, structural challenges to maintaining healthy lifestyles, and lack of tailored/adapted medical services Diversify staff, increase telemedicine, and legislation to reimburse personal trainers
Persons with physical and/or intellectual disabilities Access to exercise resources, discrimination (institutional/interpersonal), lack of access to fitness resources, challenges to maintaining healthy lifestyles, and lack of tailored/adapted medical services Increase EIM certifications specific to different disabilities, diversify staff, increase telemedicine or online training, and legislation to reimburse personal trainers
Persons living in rural areas Lack of access to medical and fitness resources, challenges to maintaining healthy lifestyles, lack of tailored/adapted medical services, and structural challenges to maintaining healthy lifestyles Increase telemedicine and legislation to reimburse personal trainers
People living in inner-city areas Access to healthcare/doctor/exercise resources, structural challenges to maintaining healthy lifestyles, and lack of tailored/adapted medical services Partner with existing resources in each city (e.g., parks, schools, churches, senior centers), diversify the training staff, increase telemedicine, and legislation to reimburse personal trainers
Elderly and pediatric populations Knowledgeable provider (comfort with prescribing exercise as medicine), lack of access to medical and fitness resources, and challenges to maintaining healthy lifestyles EIM certification, diversifying the training staff, telemedicine, and legislation to reimburse personal trainers
Undocumented immigrants and political refugees Access to healthcare facilities/doctor, comfortable/trustworthy doctor-patient relationship, structural discrimination (institutional/interpersonal), lack of access to medical and fitness resources, challenges to maintaining healthy lifestyles, and lack of tailored/adapted medical services Increase EIM certification, diversify the training staff, increase telemedicine, and legislation to reimburse personal trainers
Uninsured/underinsured Access to healthcare facilities/doctor, structural discrimination (institutional/interpersonal), lack of access to medical and fitness resources, challenges to maintaining healthy lifestyles, and lack of tailored/adapted medical services Expansion of health insurance coverage (ACA), increase telemedicine, and legislation to reimburse personal trainers
Low income Access to healthcare facilities/doctor, structural lack of access to medical and fitness resources, challenges to maintaining healthy lifestyles, and lack of tailored/adapted medical services Expansion of health insurance coverage (ACA), increase telemedicine, and legislation to reimburse personal trainers
Persons with chronic medical conditions Capacity to comply with exercise prescription challenges to maintaining healthy lifestyles and lack of tailored/adapted medical services Increase EIM certification, increase telemedicine, legislation for chronic medical conditions, tailored prescriptions, and reimbursement for personal trainers
Non-English speaking Discrimination (institutional/interpersonal), lack of access to medical and fitness resources, challenges to maintaining healthy lifestyles, lack of tailored/adapted medical services, and inability to access EIM materials if native language is not English or Spanish Increase EIM materials in multiple languages, diversify the training staff, increase telemedicine, and legislation to reimburse personal trainers
Limited health literacy Inability to comprehend EIM materials, discrimination (institutional/interpersonal), lack of access to medical and fitness resources, challenges to maintaining healthy lifestyles, and lack of tailored/adapted medical services Create EIM materials that feature less text and is available at lower reading levels and diversify the training staff

Individual-Level UVP Needs and Considerations

There are key considerations for the successful dissemination and implementation of EIM® in UVP. At the individual or patient level, consideration of UVP needs is essential. Individual patients need to understand what is considered physical activity and the health benefits of physical activity, and have access to an exercise specialist and facilities where they can sustain an exercise program (12,13). In addition, patients need providers and exercise specialists that are familiar with their beliefs and the barriers regarding physical activity participation. For example, through in-depth interviews with American Indian and African American women, Henderson identified unique cultural reasons for engaging or not engaging in physical activity (14,15). The four themes that emerged from the data were history, marginality, cultural pride, and daily living (15). The main limiting factor for physical activity in African Americans was daily living factors, and for American Indian participants, cultural pride and marginality. Many people from UVP seek culturally sensitive and inclusive exercise facilities where they feel welcome (16). Support and understanding are important factors to improve their willingness and ability to implement an exercise prescription (16). As such, the success of EIM® in these populations may be limited if providers, physical activity specialists, and/or facilities fail to address the perceived and actual needs of UVP and the barriers to patients’ experiences.

The UVP described in Table 1 also represents growing segments of society that have chronic medical conditions. Self-management of chronic conditions, in coordination with a medical team, is important to prevent disease development and progression. In a study of cancer patients, full engagement in self-management practices in those with multiple chronic conditions was present only when patients exhibited a sense of capacity (access and availability of socioeconomic resources, time, knowledge, and emotional and physical energy), responsibility (extent to which patients and practitioners agreed about the division of labor about chronic disease management), and motivation (willingness to engage in types of self-management practices) (17). In addition, patients with multiple conditions prioritize a dominant chronic illness and reprioritize the illness over time as conditions and treatments change; therefore, having multiple chronic medical conditions can reduce a patient’s willingness to engage in physical activity and/or to comply with a physical activity prescription. Potential solutions for overcoming the barriers of lower literacy and increased prevalence of chronic conditions are highlighted in Table 1. These solutions include providing EIM® materials with less text and at a lower literacy level, diversifying training staff, advocating for the expansion of health insurance (ACA) coverage including telemedicine, and partnering with existing resources.

Individual considerations including health literacy and preexisting conditions are important elements in physical activity participation. Health literacy represents an important skill that can help facilitate engagement in physical activity (18). Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (19). The association between limited health literacy and poor health outcomes has been widely documented (20). Because of historical and present-day inequities, limited health literacy is more common among individuals with limited educational attainment and low socioeconomic status, and racial minorities (21,22). Barriers at the individual or patient level should be acknowledged and evaluated to mitigate their effects in the development of effective and sustainable physical activity interventions for UVP.

Relationship-Level Considerations to EIM® Access

Engagement at the provider, patient, and healthcare-system levels is critical for the dissemination and implementation of EIM®. EIM® requires a provider to deliver physical activity counseling. Brief stand-alone counseling sessions and providers’ multiple challenges and demands (i.e., time, training issues, real or perceived limited reimbursement options, competing priorities, perceived irrelevance, poor integration into organizational routines, isolated clinic environments, misunderstanding of counseling, limited availability of local credentialed physical activity specialists) seem to limit the effectiveness for lifestyle changes (23).

Community-Level Considerations to EIM® Access

Community partners are important to EIM® access. Where community partners are available, they face the following barriers: lack of knowledge of available resources and established partnerships within clinical networks. Furthermore, patients may need a referral to alternative physical activity settings, like parks and schools, with continuous feedback and adjustment from providers and patients. Healthcare provider delivery that emphasizes coordination with clinical and community resources could be an effective way to educate patients and promote physical activity participation. Without meticulous attention to the barriers faced by providers, healthcare systems, and community partners, the capacity of EIM® to promote physical activity will be limited, especially in communities with the highest needs.

At the level of the healthcare system, the identification of resources to support the appropriate time, staff, and medical and referral resources to implement EIM® will be critical for sustainability, especially in UVP. Such resources will include trainings for medical assistants to take the exercise vital sign, for health care providers to prescribe and council on physical activity, and for EIM® professionals to be ASCM certified and available/accessible. Several conditions will be instrumental in ensuring successful implementation of EIM®, including integrating EIM® into electronic medical records, reimbursing providers for spending time in counseling, physical activity coding, and paying for patient fitness program participation.

Societal-Level Considerations to EIM® Access

The use of telemedicine services during COVID-19 has highlighted a sustainable and safe mechanism to increase access points to health care for UVP, yet disparities continue, such as differential access to digital health modalities (24,25). Fortunately, Medicare and Medicaid programs, and by extension many private payers, have responded by offering expanded coverage and reimbursement for telemedicine services to promote care. A consideration moving forward includes surveying patients to know which intervention modality would be feasible because many patients lack access to sufficient broadband and data to be able to benefit from telemedicine services (25). The need for appropriate policy changes, including increased access, are necessary to ensure equitable implementation of EIM® using telemedicine during COVID-19 and beyond (26).

This same phenomenon has also occurred in the fitness industry where synchronous online training has skyrocketed as fitness facilities have been unable to congregate in person. This medium has tremendous potential to reach and maintain patients from UVP, especially populations where structural barriers make regular physical activity outside the home challenging. EIM® materials focused on optimizing the EIM® process (assessment, referral, initiation, maintenance) in the online environment have major potential to make headway in UVP (e.g., in rural and inner-city areas, for those with disabilities). This would include transitioning the vital sign to online implementation and the referral process and certification training for fitness practitioners to work with EIM® populations remotely.

Current Health Policy and Access to Health Care: The Impact of the ACA

EIM® is a population health initiative that is dependent on access to medical care as a starting point for assessment, counseling, and referral. Although EIM® can capitalize on existing provider–patient relationships that could potentially strengthen the impact of the EIM® message, its potential reach may be hampered by reliance on the clinical encounter as a starting point, especially when considering reaching UVP.

The most basic level of access to care, as measured by having health insurance, has been an issue of societal and political importance in the United States for many years. In 2010, the US Congress passed the Patient Protection and ACA. The primary goal of the ACA is to increase access to affordable health care to millions of Americans without coverage and make health insurance more affordable for those already covered. The ACA has the potential to influence the implementation of EIM® in UVP (27,28). More than 20 million Americans have obtained health insurance under the ACA (29). African Americans, children, and small-business owners have especially benefited (27). Thirty-seven states have expanded Medicaid, deepening their pool of eligible residents to those who live at or below 138% of the federal poverty level.

The ACA waives cost sharing for all preventive services recommendations with a grade A or B by the US Preventive Services Task Force (30). The role of the Task Force is to make evidence-based recommendations about clinical preventive services, including screenings, counseling services, and preventive medications. These recommendations are assigned a letter grade (A, B, C, D, or I) based on the strength of the evidence and the balance of potential benefits and harms of that service. Under specific provisions of the ACA, insurance companies must cover A- and B-grade preventive services with no copay for adults (31). The preventive screening services most related to the EIM® initiative include blood pressure, cholesterol, depression, type 2 diabetes, and obesity, as higher physical activity levels positively affect these conditions. Other covered services related to EIM® are screening for coronary heart disease and behavioral counseling for healthful diets and physical activity for cardiovascular disease prevention. For older adults, the ACA covers screening for coronary heart disease, counseling for fall prevention, and osteoporosis screening. Pediatric and adolescent screenings mandated in the ACA that relate to EIM® include obesity and weight management screening and interventions.

It is important to note that insurance companies might not cover recommendations receiving a grade below a B by the Task Force. This includes the recommendation for initiating dietary and physical activity behavioral counseling in the primary care setting for adults without established risk factors (grade C). This coverage failure may cause providers to counsel patients selectively rather than incorporate counseling into the care of all adults in the general population, which is the primary EIM® objective.

EIM® Dissemination and Implementation Frameworks

There are methodologies and models used for dissemination and implementation of behavioral interventions including RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance). This is a pragmatic framework that has been used for EIM® implementation in various settings and populations—including diabetic patients, sedentary adults, school-aged children, employees, older adults, primary care patients, and cancer patients—and could be used for EIM® programs for UVP. Glasgow and Estabrooks (32) discuss the application of the RE-AIM framework among community and clinical settings and recognize the usability of the framework to aid in the standardization of EIM® dissemination and implementation in UVP. Opportunities exist at the provider, healthcare-system, and community-partner levels to create sustainable strategies, dialogue, and partnerships to determine reimbursement; initiatives at each step in the continuum of EIM® dissemination and implementation can be outlined using the RE-AIM framework (Table 2) (33).

TABLE 2 - EIM Within RE-AIM Framework.
RE-AIM Framework EIM
Reach The number and proportion of patients screened for physical activity levels, referred to appropriate resources, and/or provided a concrete provider prescription
Effectiveness Self-reported change in physical activity engagement, biometric measures, and/or burden of chronic conditions/comorbidities
Adoption Number of healthcare settings adopting any component of EIM
Implementation Extent that health care teams implement EIM in their settings
Maintenance Long-term effectiveness both on patient and clinic level of EIM

EIM® Dissemination and Implementation Opportunities

Dissemination and implementation literature suggests that both networks and settings matter and must be attended to intentionally for widespread adoption. The active participation of UVP in both the development and testing of the intervention is important for its successful adoption and implementation in affected communities. Importantly, EIM® has the potential to align with local capacities and priorities because of its adaptability and the diversity of physical activity’s benefits, which include everything from chronic disease prevention to quality of life, community building, and delinquency prevention (34). The dissemination and implementation literature bears these out as critical factors for success in UVP, who are likely to be skeptical about the allocation of finite time and resources to an activity with seemingly distant health benefits, when patients in need of acute care with multiple comorbidities take more time and resources than those with more straightforward and simplistic healthcare needs (35). One potential solution to this in UVP could be to design the EIM® program in such a way that it explicitly attempts to reduce the frequency of acute care crisis visits from high-risk patients, therefore aligning the goal of the program with the primary goal of the setting and increasing the likelihood of adoption and sustainment (36).

DISCUSSION

EIM® has provided a new model and resources for integrating physical activity counseling and referral into healthcare settings. The ACSM Underserved and Community Health Committee has been charged with considering how the needs of UVP can be best considered and integrated in the implementation of this program. Barriers to physical activity participation in UVP can be compounded by lack of access to or confidence in a usual source of health care or challenges in implementing EIM® in healthcare settings that traditionally serve UVP. To increase the impact of EIM® in UVP, we suggest adapting and tailoring EIM® materials for use with the needs of each population in mind and using the RE-AIM framework for dissemination. Practical steps such as the translation of EIM® materials into additional languages, diversifying EIM® training staff, and partnering with existing community programs and resources can widen the impact of EIM® in UVP. If EIM® reaches a broader and more diverse audience, more progress can potentially be made in reducing sedentary behavior and related health conditions in UVP.

We would like to acknowledge the following colleagues who participated in the symposia presented at the American College of Sports Medicine Annual Meetings in 2012, 2014, 2016, and 2018 and are not represented in coauthor group: Sofiya Alhassan, Pamela Bowen, Robert Carter, Rachel Cowan, Chris Fordyce, Litia Garrison, NiCole Keith, Andrea Kriska, Felipe Lobelo, Russell Pate, Mark Stoutenberg, Steven Stovitz, Monte Ward, and Melicia Whitt-Glover. We would also like to acknowledge Barbara Ainsworth, Maribel Cedillo, and NiCole Keith for the critical review of this manuscript and Sharla Watts for formatting assistance. The contents and findings of this manuscript represent the work of the coauthors and have not been endorsed by the American College of Sports Medicine.

The authors have no conflicts of interest to disclose. No funding was received for the preparation of this manuscript.

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