Physical inactivity is a modifiable risk factor for many chronic health problems, and performance of regular physical activity can decrease morbidity, lengthen life span, decrease depression, lessen anxiety, and prevent or mitigate functional limitations (American College of Sports Medicine [ACSM], 2009; Chodzko-Zajko et al., 2009; Paterson & Walburton, 2010; Teychenne, Ball, & Salmon, 2008). While 38% of inactive Americans report the desire to be more active, 50% drop out of exercise programs within 6 months (University of Illinois, 2011). Adults 65 years of age or older comprise 12.8% of the total U.S. population (Central Intelligence Agency, 2010). The number of people over the age of 55 years is projected to increase by 29.7% between 2008 and 2018; this rate of growth is greater than for any other age group (US Bureau of Labor Statistics, 2009). As the U.S. population ages, it becomes vital that the healthcare community effectively promote routine physical activity in an effort to delay or prevent morbidity typically accompanying the aging process.
Background and significance
Persons 65 years of age and older are the age group who are most likely to be diagnosed with chronic diseases attributable to inactivity (U.S. Department of Health and Human Services [USDHHS], 2007). More than 80% of individuals 65 years of age or older have at least one chronic condition and 50% have at least two, and by 2030 one estimate indicates more than 60% will have at least two chronic conditions (McGuire et al., 2009; USDHHS, 2011b). An inactive lifestyle accelerates biological aging; persons who exercise are biologically younger than sedentary individuals (Guralnik, 2008). The economic significance is 27% of national healthcare charges is attributed to physical inactivity and obesity, potential results of a sedentary lifestyle. Physical activity counseling has been cited as providing “exceptional value for money” (ACSM, 2009, p. 1; Anderson et al., 2005).
Increased physical activity in older adults is an inexpensive way to combat numerous preventable health problems, increase functional independence, reduce depression, slow biological aging, and enhance quality of life (ACSM, 2009; Guralnik, 2008; Paterson & Walburton, 2010; Teychenne et al., 2008; Wadsworth, 2008). Despite this opportunity, less than 20% of older adults meet physical activity recommendations (Centers for Disease Control and Prevention [CDC], 2010). The purpose of this review is to evaluate whether there is literature to support the efficacy of physical activity promotion for older adults by primary care providers (PCPs) in the primary care setting. This review will assess whether these interventions have resulted in short- or long-term increases in activity, and to identify specific intervention characteristics that are relatively effective.
Primary healthcare visits offer opportunities to promote physical activity, given that 93% of adults over age 65 have at least annual contact with a PCP (U.S. Census Bureau, 2009). Although not specific to the older adult population, the ACSM's most recent position statement advocated that all PCPs incorporate physical activity counseling into routine patient visits (Jacobson, Strohecker, Compton, & Katz, 2005). However, the multiplicity of factors that can influence a behavioral change led to the College not recommending a specific counseling intervention (Jacobson et al., 2005). Nearly 65% of patients report that they would be more interested in exercising if advised by their PCP; unfortunately, less than 34% report receiving physical activity counseling at their last visit (ACSM, 2011; Lobelo, Duperly, & Frank, 2009). This disparity between opportunity and action represents the need to recruit PCPs as a catalyst in efforts to improve lifestyle habits in an at-risk population.
Healthy People 2020 maintains the goal of “improving health, fitness, and quality of life through daily physical activity” (USDHHS, 2011a) and presents a new goal of improving “the health, function, and quality of life of older adults” (USDHHS, 2011b), which, taken together, provide support for the current review. Healthy People 2020 set a goal for 47.9% of the adult population to engage in at least 150 min of moderate intensity activity per week (Quinn, 2010). Currently fewer than 20% of older adults meet these recommendations (USDHHS, 2011b). The Physical Activity Guidelines for Americans advises older adults to engage in a weekly total of 150 min of moderate-intensity aerobic activity or 75 min of vigorous-intensity aerobic activity unless chronic health conditions prohibit (CDC, 2011; USDHHS, 2008). If the latter is the case, then older adults should engage in as much physical activity as their conditions permit (USDHHS, 2008). Ideally, physical activity episodes should be spread throughout the week and each event of activity should extend for a minimum of 10 min (USDHHS, 2008). In addition to aerobic activity, muscle-strengthening activities should be performed at least semiweekly and exercises to promote/maintain balance should be engaged in by those with fall risk (USDHHS, 2008). The impact of inactivity has been previously investigated; however, existing reviews are not specific to the elderly population and the results that can be achieved by the PCP. This review is specific to the impact of physical activity promotion interventions delivered in primary care for the older adult population.
This review aims to examine existing literature related to the effect of physical activity promotion provided in primary care on levels of physical activity in older adults. There are three specific questions evaluated in this review. What study designs have been used to research the effectiveness of physical activity interventions? Does an intervention in primary care result in short-term (i.e., ≤6 months) and/or long-term (i.e., >6 months) physical activity changes in older adults? What features of these interventions (i.e., written prescription, telephone calls, etc.) are associated with positive outcomes?
A comprehensive review of original research published in the English language from all countries through May 2010 was performed using MEDLINE, CINAHL, and ProQuest on-line databases. A systematic approach for selecting studies and a figure showing study selection was used similar to the PRISMA guidelines (Moher, Liberati, Tetzlaff, Altman, & The PRISMA Group, 2009). PRISMA is an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses, which aims to improve the quality of research and ensure the transparency and complete reporting in reviews (Moher et al., 2009). The following three criteria were established for inclusion in this review: the study assessed the effectiveness of physical activity promotion interventions implemented within the confines of a primary care setting; the aim of the study was to assess the efficacy of intervention(s) to increase levels of physical activity of older adults; and subjects were at least 50 years of age or older.
While the most recent ACSM/American Heart Association (AHA) physical activity and public health recommendations suggest that “old age” guidelines apply to individuals aged 65 years or older, because of the limited research available on this subject, the inclusion window was expanded with three additional criteria (Nelson, Rejeski, & Blair, 2007). The studies were not required to include control groups, and both randomized and nonrandomized studies were included, because it was feared that this would exclude too many studies from the review. Studies were also included that offered physical activity promotion as part of a bundled package of health promotion interventions, such as along with smoking cessation and dietary modifications. Studies in which the sole aim was to identify variables predicting participation in physical activity, such as age and gender, were excluded, as were studies that were disease specific, such as including only subjects with osteoporosis. Search terms used in CINAHL and ProQuest were: exercise OR physical activity AND elderly OR older adult AND adherence OR promotion. Terms used in MEDLINE were: exercise AND promotion AND primary care OR physician OR general practice. This resulted in 1283 unique publications.
Inclusion and exclusion criteria
All unique titles of both quantitative and qualitative studies were included and reviewed with consideration of inclusion and exclusion criteria. Titles were excluded if the study: (a) was noninterventional, (b) did not have adherence to physical activity as an outcome, (c) was performed solely to identify patient variables predicting participation in physical activity, (d) was not available in the English language, (e) was exclusively disease specific, (f) was a systematic review, (g) enrolled participants less than 50 years of age, or (h) was not available for retrieval (including studies still in progress). Of the initial 1283 studies identified, 23 potentially relevant articles remained for more extensive review. An ancestry search was also performed at this time, which resulted in four additional potentially relevant studies. The resulting 27 articles were comprehensively reviewed, with exclusion of studies that implemented intervention outside of the primary care office or utilized specialists not routinely available in the primary care office. This resulted in 11 articles, included in this integrative research review. A model demonstrating this detailed process is presented in Figure S1.
Data extraction and analysis
Independent data extraction was performed by the first author, with each of the 11 studies evaluated and extracted in chronologic order using a structured format. Data were extracted and summarized in table format on 14 topics, including: year of publication, country of setting, control group characteristics, length of study, outcome measurement tool(s), study design, sample size, intervention, and primary outcome (see Table 1).
Study designs used
The 11 research articles, including 10 quantitative and one qualitative studies, report findings from unique studies published between the years 1995 and 2009, five of which were published since 2005. Of the 10 quantitative studies, eight were randomized controlled trials. Four studies were conducted in the United States, with the remainder undertaken in Australia, England, Canada, Switzerland, or the Netherlands. In all the studies, PCPs provided some form of physical activity advice and the intervention focused on healthy older adults recruited via mailed invitations or in-office. All studies shared similar primary purposes or research questions (see Table 1).
Short- and/or long-term physical activity changes
All but one of the 11 studies (Schmid, Egli, Brian, & Bauer, 2009) reported the effect of a physical activity promotion intervention on physical activity outcomes. The Schmid and colleagues (2009) study results from focus groups with PCPs. Seven of the 10 studies reporting physical activity outcomes found that their physical activity promotion intervention was effective in increasing physical activity among enrolled subjects (Armit et al., 2009; Kerse, Flicker, Jolley, Arroll, & Young, 1999; Marki et al., 2006; Petrella, Koval, Cunningham, & Paterson, 2003; Pfeiffer, Clay, & Conatser, 2001; Pinto, Goldstein, Ashba, Sciamanna, & Jette, 2005; van Stralen, Vries, Mudde, Bolman, & Lechner, 2009). Physical activity promotion interventions were considered effective if subjects had an increase in physical activity distinct from any increase shared by a control group and/or an increase in activity from baseline. Only one study reported evaluation of whether the subjects achieved current physical activity guideline goals (Goldstein et al., 1999).
Intervention characteristics associated with positive outcomes
Physical activity intervention.
Interventions to promote physical activity were unique for each study. All but one of the studies (Burton et al., 1995) implemented a standardized intervention. In contrast, Burton et al. (1995) offered general preventive health visits aimed at health behavior modification, without any formal or structured activity promotion intervention and reported that inclusion of a general preventive visit was not effective in achieving a statistically significant increase in physical activity. Nine of the studies focused solely on promotion of physical activity (Armit et al., 2009; Goldstein et al., 1999; Marki et al., 2006; Petrella, Koval, Cunningham, & Paterson, 2003; Pfeiffer, Clay & Conatser, 2001; Pinto et al., 2005; Schmid, Egli, Brian & Bauer, 2009; Sims, Smith, Duffy, & Hilton, 1999; van Stralen et al., 2009), while two studies (Burton et al., 1995; Kerse et al., 1999) offered physical activity counseling as part of a healthy lifestyle package including immunization and alcohol and smoking cessation. Implementation of a multidimensional bundled intervention for promotion of a healthy lifestyle was recommended in the qualitative study by Schmid et al. (2009).
Verbal advice was the most common tool for physical activity promotion and was a component of all studies, except the research of van Stralen et al. (2009), which relied solely on print and computer-based interventions. Nine of the studies' interventions included some form of printed material, such as an exercise prescription, schedule, contract, or guidelines. Supplementing verbal advice with written advice did not show a statistically significant effect on physical activity outcomes in the one study that specifically investigated this (Pfeiffer et al., 2001).
Length of time for intervention.
Six studies reported the average amount of in-office time spent on the physical activity intervention at the initial visit; these times ranged from 3 to 15 min. Armit and colleagues (2009) reported that brief intervention was effective in increasing physical activity. Of the three studies reporting interventions lasting 11–15 min (Marki et al., 2006; Petrella et al., 2003; Pfeiffer et al., 2001), all reported that intervention subjects significantly increased their physical activity.
Three studies reported giving provider reimbursement for the visit and/or for the time needed to train the provider to deliver the intervention (Burton et al., 1995; Goldstein et al., 1999; Pinto et al., 2005). Provider reimbursement was recommended by a focus group of PCPs in the qualitative study by Schmid et al. (2009). Of the studies providing reimbursement, only one found the intervention to have a positive effect on physical activity (Pinto et al., 2005).
The negative consequences of a sedentary lifestyle present an opportunity for nurse practitioners (NPs) to make a significant impact on a large and growing older patient population that is already routinely seen in primary care. This review demonstrated that provider-delivered physical activity promotion during routine primary care consultations has the potential to produce at least short-term increases in activity levels among older adult patients (Armit et al., 2009; Kerse et al., 1999; Marki et al., 2006; Petrella et al., 2003; Pfeiffer et al., 2001; Pinto et al., 2005; van Stralen et al., 2009).
Study designs used
A variety of study designs were considered for inclusion in this review, because in the area of health promotion, restriction to only randomized controlled trials would have omitted potentially relevant studies. Randomized and nonrandomized trials were included in this review, as well as qualitative research. Of the eight studies that were reported to be randomized controlled trials, four did not integrate true control groups (Armit et al., 2009; Petrella et al., 2003; Pfeiffer et al., 2001; Pinto et al., 2005). These trials used controls that received varying intensities of physical activity counseling, which may have been atypical of a general primary care visit; consequently, outcomes may have appeared blunted and lacked statistical significance. This review was restricted by the limited number of high-quality studies meeting the established inclusion criteria; however, taken together the studies included more than 6000 primary care patients.
Each of the studies in this review was an original primary study, and durations, data collection tools, and practice settings varied; these covariates limited comparison of efficacy of each intervention and identification of trends. Self-report was the primary method used for outcome measurement in all studies, and this method is subject to recall and social desirability bias, and a Hawthorn effect was identified in one (Sims, Smith, Duffy & Hilton, 1999).
Randomization by patient was utilized in five of the studies, and this design style is susceptible to cross contamination and may result in carry-over effects, as there is the potential for the PCP to unintentionally deliver counseling to control subjects (Armit et al., 2009; Burton et al., 1995; Pfeiffer et al., 2001; Pinto et al., 2005; Sims et al., 1999). Analysis by intention to treat is an appropriate form of analysis for this style of research because of the high potential for dropout; however, this was only reported to be used in six of the studies (Armit et al., 2009; Burton et al., 1995; Kerse et al., 1999; Petrella et al., 2003; Pfeiffer et al., 2001; Pinto et al., 2005).
Short- and/or long-term physical activity changes
This review demonstrated that intervening has the potential to produce at least short-term increases in activity levels among older adult patients (Armit et al., 2009; Kerse et al., 1999; Marki et al., 2006; Petrella et al., 2003; Pfeiffer et al., 2001; Pinto et al., 2005; van Stralen et al., 2009). Unfortunately, there is limited evidence to evaluate whether these interventions are effective in producing and sustaining long-term changes. However, this lack of evidence does not demonstrate ineffectiveness. The interventions implemented in the short-term studies could have potentially resulted in long-term changes. The ability to produce long-term adherence is fundamental, as research has shown that physical gains are quickly lost after cessation of an exercise program (Quinn, 2010). The results of this review, which focused specifically on older adults, are consistent with existing reviews that have studied adults in general—intervention is effective in achieving short-term increases in physical activity, but there remains insufficient evidence to establish whether intervention is effective to promote and sustain long-term increases in physical activity (Eakin, Glasgow, & Riley, 2000; Eaton & Menard, 1998; Foster, Hillsdon, & Thorogood, 2005; Lawlor & Hanratty, 2001; Sorensen, Skovgaard, & Puggard, 2006).
Intervention characteristics associated with positive outcomes
Written material was incorporated into most interventions, and while Pfeiffer et al. (2001) reported that supplementing verbal advice with a written physical activity prescription did not demonstrate any statistically significant effect on physical activity outcomes, patients consistently reported a preference for interventions including a written contract or prescription.
The option of implementing a multifactorial or “bundled” intervention must also be considered. Multifactorial interventions, which target several modifiable risk factors, such as sedentary lifestyle, tobacco use, and alcohol abuse, may be the most effective method of activity promotion and was recommended, although this was not thoroughly studied in this review (Burton et al., 1995; Kerse et al., 1999; Schmid et al., 2009). This act of “bundling” interventions has been demonstrated as effective in computer-tailored interventions (Oenema, Brug, Dijkstra, Weerdt, & Vries, 2008) and has been effectively used in conjunction with smoking cessation programs (Everson-Hock, Taylor, Ussher, & Faulkner, 2010; Taylor, Everson-Hock, & Ussher, 2010).
As a whole, the more time-intensive interventions had a higher efficacy rate than brief interventions, suggesting a possible relationship between length of time spent on intervention and physical activity outcomes, although this will require further study.
Preventive health interventions have the potential to serve as cost-effective strategies, which can reduce morbidity and mortality (Cohen, Neumann, & Weinstein, 2008; Maciosek, Coffield, Edwards, Flottemesch, & Solberg, 2009). This review, while limited by its size, demonstrates that a brief office-based physical activity counseling session has potential and deserves further study. When conducting future research on this focus, it is recommended that study designs address the limitations of existing research, including length of follow-up, sampling methods, subanalyses, and outcome measurement tools.
Over 16.2% of the nation's gross domestic product is consumed by healthcare expenditures (Centers for Medicare and Medicaid Services, 2010). As a result, health-economic evaluations must be incorporated into future research to evaluate whether any effort to improve physical activity levels is an efficient use of resources. This review focused on the effectiveness of interventions implemented solely by the PCP. Future study should compare the efficiency and effectiveness of interventions implemented solely by PCPs to those utilizing ancillary healthcare members and “specialists.”
Future research also should examine the effectiveness of integration of more modern technologically based interventions, such as text messaging and social networking, to facilitate physical activity changes. Older adults today are more technologically savvy than ever before and are likely to be receptive to the use of technology when it may be used to address health care (Jennings & Richert, 2006). As long-term adherence is of concern, interventions incorporating tools readily accessible on a daily basis, such as the Internet, may maximize the duration of change and facilitate long-term follow-up, a weakness found by the current study. This may also include study of the need for and timing of booster interventions to achieve long-term adherence.
Practice and policy implications
By definition, the PCP is the primary health resource utilized by older adults. Owing to this dynamic, PCPs have a unique opportunity and responsibility to promote reduction of modifiable risk factors for chronic disease. One of these risk factors is a sedentary lifestyle. Such health promotion is essential, but time consuming, as PCPs face an aging population that strains healthcare services, with adults over age 65 consuming twice as many physician services per capita than their younger counterparts (American Medical Association, 2008). Further compounding this supply and demand mismatch is the steady decline of physicians choosing to practice in primary care (American Medical Association, 2008). As a consequence of these factors, NPs are filling this void.
The websites listed in Table 2 provide clinicians with links to recommendations for promotion of activity, as well as current guidelines. Table 3 also provides a listing of sites to which patients may be referred; these resources offer motivational facts, benefits of physical activity, tips to staying active, sample exercises, and charts to record progress. Changes in healthcare policies are needed to make it more feasible to implement the recommendations resulting from this review. PCPs are faced with the issues of provider time constraints (Konrad et al., 2010), lack of financial incentives or reimbursement for health promotion (Horsley, Belza, & Brown, 2009), and insufficient knowledge about the most effective counseling strategies (Horsley et al., 2009).
Providers have identified the aspect of time as a key variable impacting the quality of care, citing that rushed care is low-quality care (Horsley et al., 2009). Allocating additional patient-visit time to physical activity counseling may further rush the patient visit. It would therefore be necessary to address the issue of reimbursement for physical activity counseling. One report projected that an investment of $10 per person per year in intervention to promote physical activity, improved nutrition, and smoking cessation could save more than $16 billion annually within 5 years—a return of $5.60 for every $1 invested (Trust for America's Health, 2009).
Healthcare system policies need to use methods such as tracking, benchmarking, and feedback to both educate and motivate PCPs to optimize interventions to promote physical activity in their patients. A potential solution would be third-party payers instituting “pay-for-performance” agreements to promote primary prevention, in which PCPs are expected to achieve benchmarks in patient outcomes, while using minimum resources. Third-party payers may also incentivize individual patients by offering reduced insurance premiums for those who participate in physical activity programs.
A sedentary lifestyle is associated with chronic disease, premature death, and economic burden, summarized by the term sedentary death syndrome (Lees & Booth, 2004). Treatment of morbidity attributable to inactivity is an inefficient approach—primary prevention is the key. It is known that health and function can be improved after initiation of physical activity in persons who were previously sedentary, and that there are few contraindications to adoption of a physical activity routine (Mazzeo et al., 1998; Woo, Derleth, Stratton, & Levy, 2006). Many patients are interested in modifying their sedentary lifestyle, and willing to take advantage of available resources. This review demonstrated that physical activity promotion by the PCP can lead to at least short-term increases in physical activity. Intervention should include written activity prescriptions, target multiple modifiable risk factors, consider each patient's barriers and supports to becoming physically active, and allocate sufficient time for a high-quality intervention. It is time for all PCPs to shift their focus from a reactionary style of treatment of disease to a proactive promotion of health and prevention of disease, including physical activity promotion.
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Additional Supporting Informationmay be found in the online version of this article.
Figure S1: Summary of search strategy
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