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Abstract
Background Healthcare providers are a primary source of information on preventive health issues for patients. Further research related to physical activity (PA) promotion in the primary care setting is needed.
Objective To explore the feasibility of a physician and community PA intervention using a pedometer for: increasing PA levels among inactive patients; enhancing relationships between physicians and community PA partners; and influencing the PA promotion habits of physicians.
Methods A 6-week PA intervention was delivered to 152 inactive patients who were recruited in physician waiting rooms, counselled by their physicians, provided with a pedometer and referred to a community action site (CAS) at their local recreation centre for further support. PA was measured at baseline and follow-up using the International Physical Activity Questionnaire. Follow-up interviews were conducted with physicians and recreation representatives on the challenges and benefits associated with the intervention.
Results Study patients significantly increased their PA (103% change in MET min/week). Physicians and recreation professionals were highly satisfied with the intervention and partnership. There were challenges to ongoing communication. Physicians reported increased awareness of the pedometer and community resources as supports for PA.
Conclusion A pedometer-based PA intervention delivered by physicians in partnership with a community PA stakeholder is feasible and warrants further research. Long-term maintenance of this intervention would require resources for pedometers, and ongoing contact and communication between the physicians and CAS to ensure availability of community supports.
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Introduction
Physical activity (PA) participation is associated with a decrease in cardiovascular disease, obesity, type 2 diabetes mellitus, colon cancer and osteoporosis.1 2 Despite the established benefits of PA, substantial proportions of the global population are sedentary. Approximately, 52% of Canadians fail to meet the recommended health guidelines of 30 min of moderate PA almost every day.3 Therefore, PA promotion is a public health priority.
Healthcare providers are a primary source of information on preventive health issues for patients.4 Physicians have high credibility and, thus, are positioned as an important influence in the behaviour change cycle.5 The reach of physician-based interventions is potentially high, with 70% of adults reporting at least one physician contact each year.6 Although physicians acknowledge the importance of PA and are supportive of guidelines regarding physician advice about PA, few incorporate advice routinely into medical visits.4
Research related to PA promotion in the primary care setting7 8 varies widely. Several studies have supported the short-term (ie, up to 8 weeks) and long-term (ie, 4–24 months) effectiveness of physician counselling for activity, and have demonstrated its feasibility and acceptability as a population health strategy.4 6,–,13 However, a systematic review of eight controlled trials revealed that verbal physician advice during consultations does not produce sustained increases in PA levels.14 To support healthy behaviour change, researchers have recommended that physicians use community-based resources, such as programmes, support groups and interactive websites.15 Flocke et al15 found that a practice-tailored intervention integrating an information prescription tool and referral to community resources for healthy behaviour change increased the rate of discussion of PA, diet, weight management and referral to community resources.
Further, Kallings et al16 evaluated the feasibility and effects of PA on prescription in a routine clinical setting on PA level and quality of life after 6 months. Increases in PA levels, stages of change and quality of life were noted, demonstrating that PA on prescription may be appropriate as a conventional treatment in a primary healthcare setting to promote a more physically active lifestyle. Grandes et al17 examined the effectiveness of family physicians to increase PA in inactive patients using a new ‘Experimental Program for Physical Activity Promotion’ (PEPAF, following the Spanish translation). Physicians randomised to the PEPAF arm (n=29) provided brief advice and educational materials to all patients, as well as an individualised PA plan. Control group physicians (n=27) delivered standard care. Significant increases in PA levels were seen in patients in the PEPAF programme implemented by family physicians after 6 months compared with the control group.
Pedometers provide another mechanism to support behaviour change. These inexpensive, easy-to-use devices measure daily PA,18 19 and can assist self-monitoring and goal setting by providing feedback supporting adoption and maintenance.20 21 Pedometer use is associated with significant increases in PA and clinically relevant reductions in body mass index and blood pressure.22
To our knowledge, there have been five pedometer-based studies conducted in primary care settings23,–,27 and four pedometer-based community interventions.21 28,–,30 Of these, three studies included pedometers in a PA intervention delivered by clinical staff (ie, not physicians).23 25 27 Pickering and Eakin23 used a pedometer-based intervention with low-income participants attending a Family Planning clinic and found them feasible to use with this typically difficult-to-reach population. Armit et al25 found that targeted advice from an exercise scientist in combination with pedometer use resulted in short-term increases (ie, 12-week intervention) in PA levels in inactive patients 55–70 years of age. Conversely, Stovitz et al27 found that the pedometer provided no additional PA benefit to a brief physician counselling session.
Based on the emerging evidence, PA stakeholders in British Columbia, Canada formed a partnership to implement a physician and community PA intervention using pedometers to increase PA levels among inactive patients. We used this real-world intervention to explore the feasibility and potential impact of the pedometer and community partnership approach on patient PA levels, physician/community relationships and self-reported PA promotion habits of physicians.
Methods
Study participants
Recruitment occurred in two phases. First, physicians (n=6) and community action sites (CASs) and coordinators (n=2) were recruited from two urban ‘active communities’ to implement the intervention. (The Active Communities Initiative was a cross-sectoral initiative focused on supporting communities to increase PA levels of British Columbians by 20% by the year 2010. The initiative mobilised and collaborated with communities, local governments, First Nations and partner organisations to promote healthy lifestyle choices, increase accessibility to physical activities and build supportive community environments. The initiative was delivered by British Columbia Recreation and Parks Association with funding from the Provincial Government through ActNowBC and in partnership with 2010 Legacies Now. A registered Active Community was one that had voluntarily made a commitment to work towards the goal of 20% increase by the year 2010; to build an Active Communities team and to develop an Active Communities plan.) These centres were chosen because they had local community PA resources and staff in place to implement the patient support. Second, patients were recruited during their visit to their physician using a tent card on the medical reception desk. Eligible patients were 19 years or older and physically inactive. Patients were considered inactive if they responded to the precontemplation, contemplation or preparation descriptor on a Stages of Change screening questionnaire administered at recruitment. The Stages of Change, a key construct of the Transtheoretical model,31 are a series of five stages that individuals progress through when adopting a new health behaviour, including: precontemplation (ie, no PA and does not intend to take action in the next 6 months), contemplation (ie, intends to take action within the next 6 months), preparation (ie, intends to take action within the next 30 days and has taken some behavioural steps in this direction), action (ie, regular PA for less than 6 months) and maintenance (regular PA for more than 6 months). Marcus et al's32 33 algorithm was used to classify stages of change. One hundred and fifty-nine eligible patients agreed to participate in the study and provided informed consent. One hundred and forty completed baseline questionnaires (17 individuals participated and provided follow-up data only).
PA intervention
Once patients agreed to participate, their physician counselled them on the benefits of PA, helped them establish PA goals, provided them with a pedometer, demonstrated how it worked and referred them to a CAS. Patients also received a folder containing a logging sheet and web address for internet-based step monitoring, a referral card to the CAS and information about relevant community services and walking routes. The CAS coordinator contacted patients by telephone 1 week into the intervention to provide follow-up support. During this call, the coordinator addressed pedometer use, the resource folder and any concerns the patient raised. Patients were contacted for follow-up at 6 weeks.
Instrumentation
Physical activity
The short version of the International Physical Activity Questionnaire (IPAQ) measured PA at baseline and postintervention (6 weeks).34 The IPAQ was self-administered in the physician's office at baseline and by telephone interview at follow-up. Demographics (ie, age, gender and education level) were collected at baseline. At follow-up, 10 additional open-ended questions collected information on the intervention and how it may have influenced the patient. The questions addressed: the impact of intervention components (pedometer and physician counselling) on their awareness of community resources and their PA, whether they incorporated walking, whether they contacted the CAS for support, factors influencing pedometer use and other thoughts.
Patient daily steps log entries
Patients were asked to record their daily step count using a paper logging sheet or a web-based tracking system. If patients used written forms, they were asked to fax or drop them off at the CAS.
Physician/community partnerships and PA promotion habits
Follow-up telephone interviews were conducted with five physicians and two CAS representatives. Of the six physicians, one was unavailable, and the clinic nurse practitioner was interviewed. Interviews addressed the physician/community partnership, physician PA promotion (physicians only), and challenges and benefits associated with project participation and pedometers. CAS coordinators also kept a written log of attempted and successful contact calls and issues that arose in relation to pedometer use and resource materials.
Statistical analysis
Data from the IPAQ were entered into SPSS 12.0. Descriptive statistics were calculated for all variables, and frequency distributions were generated for categorical variables. Paired-samples t tests (for interval level data) and Wilcoxon signed ranks tests (for ordinal level data) were used to determine if there were any differences between baseline and follow-up.
The qualitative data were entered into Excel. Two research assistants conducted content and thematic analysis using established methods, such as clustering and coding,35 36 to determine respondent views and perceptions and uncover emerging themes. Following initial coding of the themes, the researchers then reviewed the data and themes to determine higher-order themes.
Results
Thirty-two of the 140 patients who had baseline data were not available for follow-up. Of the 32 individuals who were not available, 25 could not be reached after three attempts (and therefore their status is unknown), three were away during the intervention, two were sick or injured, one had family visiting, and one was discouraged owing to an inability to achieve 3000 steps per day. Seven extreme cases were removed from the analysis (PA data were more than three SDs away from the mean37). Therefore, predata and postdata were available for 101 respondents. Demographic information on the patients is displayed in table 1.
Demographic characteristics of the patients
Dropouts between baseline and 6-week follow-up revealed no significant differences for age, gender and education level.
Quantitative data
Patients (n=101) significantly increased their PA and estimated energy expenditure (table 2). There was a significant increase in total energy expenditure recorded using metabolic equivalents of task (MET) between baseline (1568.24 MET-min/week) and follow-up (3189.50 MET-min/week) (figure 1). This increase was largely due to significant increases in walking frequency (figure 2). The amount of moderate and vigorous PA per day appeared to increase, but not significantly (figure 2). Patients also significantly decreased their sedentary behaviour (eg, number of min/day spent sitting) from 415.94 min/week at baseline to 321.00 min/week (figure 3).
Mean differences on metabolic equivalents of task (MET) minutes by International Physical Activity Questionnaire (IPAQ) physical activity category. *p<0.05, **p<0.001.
Frequency of physical activity (PA) based on the International Physical Activity Questionnaire (IPAQ) category—days/week. **p<0.001.
Mean differences in mean min/day of vigorous and moderate physical activity, walking and sitting. **p<0.001. IPAQ, International Physical Activity Questionnaire.
Differences between physical activity days and levels between baseline and follow-up as measured by the International Physical Activity Questionnaire
At baseline, almost two-thirds of patients were classified as inactive (achieving less than 30 min of moderate vigorous PA most days of the week), and at follow-up, this had dropped to one-quarter (figure 4). At follow-up, 72% of the patients stated that it was quite or very likely that they would continue walking in the future (figure 5).
Change in International Physical Activity Questionnaire (IPAQ) physical activity categories between baseline and 6-week follow-up. *Low, not meeting the guidelines for health; Moderate, 30 min/day of moderate–vigorous physical activity on most days; High, 1 h/day or more of moderate–vigorous physical activity on most days.
Self-rated likelihood of continuing to walk after the pedometer intervention.
Qualitative data
Influences on patient participation
Of the 101 patients, 96 (95.0%) reported making changes in their lifestyle as a result of participating in the intervention. Some examples included parking further away from a destination, starting to ride a bike, walking at work and setting step count goals. Patients also reported weight loss, improved sleep and overall energy increases since starting the pedometer intervention. Conversely, low PA levels during the study were attributed to musculoskeletal problems, lack of time and illness (cold or flu).
Collaboration between physicians and CAS
From the interviews conducted with physicians and CAS coordinators, there were several indications that collaboration between physicians and CAS was a successful component of the intervention. The collaboration provided physicians with a better understanding of services and support available to their patients, and the CAS were very much interested in providing support to patients (see table 3 for sample quotes).
Collaboration between physicians and community action sites (CASs): sample quotes
Both physicians and CAS coordinators thought that the intervention laid the groundwork for a relationship between the two groups, but that the relationship could have been further enhanced. For example, one CAS coordinator stated, ‘although the connection was made initially in the first meeting, there was nothing after that to keep the two groups connected’ (table 3).
Influences on physician PA promotion and implementation
The intervention also had a positive impact on physicians' PA promotion behaviours. Many physicians stated that the intervention increased their awareness of the usefulness of the pedometer and the various resources available in the community (see table 4 for sample quotes).
Influences on physician physical activity promotion and implementation: sample quotes
Some of the physicians interviewed said they were attracted to the intervention because it provided an opportunity to encourage healthy lifestyles with their patients. One physician stated, ‘I thought it would be a good chance to assist in the lifestyle changes for our patients.’ Another commented that the intervention helped him work with patients to identify and attain goals rather than ‘simply prescribing a pill’ (table 4).
Both patients and physicians indicated that a lack of time was the greatest challenge for implementation and uptake of the intervention. Physicians stated that remuneration from the government for lifestyle counselling, the availability of resources (pedometers and CAS support) and documentation of the positive effects of the intervention acted as key influences on ongoing implementation (table 4).
Discussion
The primary purpose of this study was to increase PA levels among inactive patients by implementing a physician and community PA intervention using the pedometer. This physician and community PA intervention significantly increased walking and decreased sedentary behaviour in a self-selected group of inactive patients.
Similar to our study, Stovitz et al27 tested the efficacy of a physician-delivered pedometer intervention (N=94) during routine visits to a family medicine clinic using a randomised design, and found positive results. In their study, pedometer steps significantly increased from week 1 to 9 (on average 41% improvement) with significant improvements in: number of blocks walked per day, number of blocks walked versus driven, climbing stairs versus taking an elevator, frequency of walking ≥30 min, walking short trips and walking for fun/leisure. Similar to their study, we also found increases in total energy expenditure between baseline and follow-up related to frequency of walking and decreases in sedentary behaviour. However, our study differs from Stovitz et al's27 study in that we incorporated a community component.
Congruent with the work of Stovitz et al27 and our study, Pickering and Eakin23 examined the feasibility of pedometers with predominantly low-income clients (N=35) attending a family-planning clinic. They found a statistically significant increase in PA from baseline to 2 weeks post-trial, but these changes were not sustained at 8 weeks. Sherman et al24 also found increases in step counts after a pedometer intervention within a primary care practice. Comparisons across studies are constrained by methodological variability, but our findings join a growing body of evidence highlighting the efficacy of the pedometer as a support for short-term behaviour change.
Our study is unique in establishing and exploring the collaboration between physicians and the community to support intervention. At the patient level, however, very few (2%) initiated contact with the CAS, making it difficult to determine the CAS's importance to adherence. The low level of contact between patients and CAS may be due to the initial call from the CAS, where the staff discussed pedometer use and the resource folder, and addressed any concerns that the patient raised. Also, there may be other factors such as low physician referral or patient disinterest contributing to the low level of contact.
Most physicians expressed interest in continuing patient referral to CAS and perceived their role in health promotion to be enhanced. CAS commented that they were also delighted to be working with physicians. However, both physicians and CAS felt that communication could have been improved. The CAS received very few enquiries from the patients and physicians and, as a result, were uncertain about the referral process. Physicians stated that they did not receive feedback from the CAS as to who had connected with the site and how they were progressing. This challenge in communication is an area to address in future initiatives.
The intervention had a positive impact on physician attitudes and PA promotion habits. Physicians reported an increased awareness of the usefulness of the pedometer and the various resources available in the community. They also valued the opportunity to assist patients in lifestyle changes. This is consistent with previous research conducted by Jimmy and Martin.38 Most of the physicians in their study reported appreciating being given materials and an incentive to discuss the issue of PA with their patients.
Similarly, a feasibility study conducted in a Dutch general practice found that the overall impression of the majority of the care-providers was positive in terms of the usefulness and the delivery of the PA intervention.39 In another feasibility study, patients received the counselling of PA on prescription from their usual healthcare professional as a part of routine primary healthcare, and the results show that the trial significantly changed the patient's behaviour to a more physically active lifestyle 6 months after receiving the prescription.16
Although our study provides evidence that physicians value the opportunity to promote PA among their patients, lack of time was viewed by the physicians as the greatest challenge to implementing the PA intervention into their practice. This is consistent with previous studies, where problems such as lack of counselling skills, perceived ineffectiveness of counselling, lack of time, lack of organisational support, little or no reimbursement and limited availability of educational materials were the most commonly cited barriers to PA counselling.6 40 41
Our findings are limited by the nature of the evaluation design (no comparison condition). The sample was self-selected, which may limit the generalisability of findings. Self-report PA measures are also vulnerable to recall error, social desirability, and other biases. Despite these shortcomings, the results from this current study provide preliminary evidence that implementing a pedometer intervention within a primary care setting and in partnership with the community may be an effective approach to increase PA levels among inactive patients.
Conclusion
Our study extended the literature on the use of pedometers as an intervention tool in primary care and demonstrated the feasibility of implementing a pedometer intervention in partnership with the community. This physician and community PA intervention was successful in increasing walking and decreasing sedentary behaviour among inactive patients. Establishing the support of physicians and the CAS was critical to the success of the intervention. The physicians valued the opportunity to assist in lifestyle changes for their patients. Physicians are an optimal community resource for the dissemination of health promoting materials such as pedometers because of their credibility and wide reach. The CAS, situated in a community recreation facility, was a good fit for patient follow-up and providing a supportive environment. Long-term maintenance of this intervention approach would require support for ongoing communication between the physicians and CAS and the necessary resources to encourage PA and follow-up with patients. The findings of this evaluation support a broader implementation trial and enhanced evaluation (randomised comparison condition and longer follow-up).
What is already known on this topic
Physicians are an important and credible source for advice on physical activity (PA) and can have a modest short-term impact on PA.
What this study adds
Our study extended the literature on the use of pedometers in primary care and demonstrated the feasibility of partnering with community. The intervention had a positive impact on physician attitudes and PA promotion habits. Physicians reported an increased awareness of the usefulness of the pedometer and the various PA resources available in the community.
Acknowledgments
The authors would like to acknowledge the contributions of the project partners including the BC Medical Association (BCMA), the two communities of Penticton and Abbotsford in British Columbia, the physicians and community actions sites involved, in recognition of their collective wisdom upon which this paper is based.
References
Footnotes
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Funding This work was supported by the British Columbia Recreation and Parks Association. LT is supported by Full-Time Health Research Studentships from the Alberta Heritage Foundation for Medical Research.
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Competing interests None.
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Ethics approval Ethics approval was provided by the University of Victoria.
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Provenance and peer review Not commissioned; externally peer reviewed.