How to make exercise counseling more effective: Lessons from rural America

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Original Research

How to make exercise counseling more effective: Lessons from rural America

J Fam Pract. 2008 June;57(6):394-402

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References

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Our objectives. The first objective of this study was to identify the prevalence of specific components of physician counseling in a tri-state sample of at-risk, rural adults using telephone survey data. A second objective was to measure the longitudinal relationship between physician counseling and physical activity.

Methods

The Saint Louis University Institutional Review Board approved this study.

Study population and design

This study reports on baseline and 1-year follow-up telephone survey data collected as part of a larger 3-year intervention study in 12 rural communities from Missouri (6), Tennessee (4), and Arkansas (2). Project WOW (Walk the Ozarks to Wellness) aims to promote walking among overweight rural adults by integrating individual, interpersonal, and community-level interventions. Methods and details of the intervention are described in detail elsewhere.²⁴ The target communities ranged in population from 766 to 12,993 adults, and in geographic area from 1.4 to 16.1 square miles.²⁵

At baseline in the summer of 2003, we used a modified version of the Behavioral Risk Factor Surveillance System (BRFSS) interview protocol^26,27 and randomly dialed telephone numbers to recruit participants residing within a 2-mile radius of a walking trail. In all, 2470 English-speaking adults, ages 18 and older, completed the baseline survey (65.2% response rate).²⁸ Sampling was proportionate to community size.

At follow-up in the summer of 2004, participants identified at baseline completed the same telephone survey used a year earlier. This time, 1531 participants completed the survey (62.0% response rate).²⁸

Demographic variables included age, sex, education, race/ethnicity, and annual combined household income (TABLE 1). Overweight and obesity, based on self-reported height and weight, were defined by a body mass index (BMI) of 25 to 29.9 kg/m² and 30 kg/m² or greater, respectively.

TABLE 1
The population sample

PATIENT CHARACTERISTICS	FOLLOW-UP SURVEY (N =1141) %
Female	74.6
White, non-Hispanic	94.6
Education
Less than high school	9.7*
High school graduate	30.8
Some college	23.9
College graduate	35.6
Age
18-24	6.4*
25-44	35.4
45-64	39.1
65+	19.1
Annual household combined income (n=1102)
< $25,000 31.7*
‡ $25,000	68.3
Body mass index (n=1107)
Normal (<25)	43.7
Overweight (25-29.9)	31.5
Obese (‡ 30)	24.8
Physician encounters/counseling
Has doctor for regular care	87.8*
In usual year, has seen doctor ≤1 time	28.2*
Has been advised to exercise more	35.1
Doctor helped develop plan to exercise more	33.8
Doctor followed up on plan to exercise more	46.3
* Significant P value <.001 between responders and nonresponders at 1-year follow-up.

Measurement of dependent and independent variables

The survey instrument incorporated questions from the BRFSS, as well as questions developed by researchers from San Diego; Sumter County, South Carolina; and St. Louis.^29-34 Psychometric properties of the questions and scales are reported elsewhere.³⁵ The survey instrument contained 106 questions, including skip patterns; the average administration time was 34 minutes.

We assessed physician counseling about exercise with 5 questions from the survey (TABLE 2). These questions were modeled on the “4 As” counseling approach (Ask, Advise, Assist, and Arrange follow-up) recommended by the National Cancer Institute³⁶ and used in a previous, similar BRFSS-based telephone survey.¹⁵ The questions were:

Do you have a doctor whom you see for regular health care?
In a usual year, how often do you see your doctor?
Have you been advised within the last year by a doctor to exercise more?
Has your doctor helped you to develop a plan to increase exercise?
Has your doctor followed up with you at subsequent visits to see how you increased exercise?

We administered the questions at baseline and at follow-up. For our analyses, we used patient reports of physician counseling at 1-year follow-up, which covered all counseling received in the past 12 months.

We considered respondents to have met recommendations for physical activity if they had engaged in prescribed moderate or vigorous physical activities, or had walked for exercise 150 minutes a week.

Moderate physical activity was defined (according to the current CDC recommendations) as 30 cumulative minutes of moderate-intensity activity (brisk walking or jogging) at least 5 days per week.¹

Vigorous physical activity was defined as 20 minutes of vigorous-intensity activity (running) at least 3 days per week.¹

The sample was limited to participants who completed the baseline and follow-up surveys, and who reported at follow-up that they had no physical impairment that prevented walking (n=1141).

Statistical analysis

To evaluate how physician counseling would change a patient’s physical activity between baseline and 1-year follow-up, we used multivariate logistic regression analysis. In accordance with the questions asked in the survey, we defined 5 potential predictors of a patient’s decision to start exercising and keep exercising:

Patient has seen a doctor for regular care.
In a usual year, patient has seen a doctor once or less.
Patient has been advised to exercise more.
Doctor helped develop a plan to exercise more.
Doctor followed up on plan to exercise more

For every patient who met physical activity recommendations at the 1-year follow-up, we performed regression analysis on each of these 5 measures, adjusting for baseline physical activity and potential confounders of age, education, and sex. This method allowed us to examine the independent effect of physician counseling on physical activity at 1-year follow-up.