When it comes to what effect clinician-based counseling programs have to promote physical activity in underserved populations, information is scarce and inconsistent. Physical inactivity and poor health outcomes related to sedentary behavior disproportionately affect underserved groups, yet these populations have not been systematically included in clinical trials.
This reflects in part the difficult task of designing and implementing realistic interventions in these settings. However, interventions must be replicated in underserved populations before we can necessarily assume that findings from other trials are generalizable, due to issues of access, financial resources, health literacy, beliefs, cultural differences, self-efficacy, and other logistic barriers to traditional care that disproportionately affect underserved groups.
Integrate known personal, social, and environmental factors
have explored the social, demographic, and environmental factors associated with physical activity in minority populations. These studies shed light on the reasons why clinical trials that focus on white, affluent, educated populations might not be generalizable to underserved groups.
Interventions to promote physical activity in the underserved need to incorporate factors that are associated with success and find ways to address any barriers to be maximally effective. For example, among African American and Hispanic women, having lower “social role strain,” higher attendance at religious services, and a greater feeling that one’s neighborhood was safe were all associated with increased likelihood of exercise.24–26
Such studies suggest that differences in beliefs, resources, self-efficacy, prior experience, and competing life demands can all contribute to promoting physical activity in some underserved groups. Practically, such findings encourage clinicians to work with patients to help them identify sources of social support, positive influences on their health, and help them articulate internal strengths and personal attributes to succeed in behavioral change.
Despite the variations in training or means of communication in the studies we identified, some interventions were successful16,22
and improved physical activity. Specifically, these successful trials explicitly anticipated and addressed barriers and challenges to physical activity. These 2 studies also had interventionists who represented the community (or communities) of interest, and they used cultural adaptations to promote exercise where appropriate. Thus, limited data suggest that some primary care–based programs improve physical activity in underserved patients, but the effects of communication from the primary care clinician on physical activity is lacking, consistent with other work in the field.12,27
Promising intervention strategies include office prompts, brief counseling
Primary care clinicians face many time pressures, fiscal constraints, administrative burdens, and competing priorities—these make addressing health promotion behaviors such as physical activity quite difficult. These issues are magnified for clinicians practicing in medically underserved areas. Despite these many challenges, promising opportunities do exist.
On a systems level, practice-based systems
to manage chronic diseases have been successfully developed and implemented in the primary care setting; these can be tested to promote physical activity as well. Such practice-based approaches include patient registry data, office prompts, and other electronic systems to promote clinician counseling. For example, studies in this review using computer-based programs in primary care offices were feasible and effective.18,19,22
has argued for a redesign of primary care systems to more effectively address chronic conditions rather than acute care needs; several health care systems have successfully implemented the pillars of such a redesign imperative and shown convincingly the promise of addressing competing priorities, physician competence and confidence, motivation, and durability in improving patient self-management.28
At the level of the clinician-patient relationship
, data suggest that patient physical activity can be increased (at least in the short term) by counseling that is:
- brief (5 minutes or less)17–20,23
- molded to the patient’s specific health needs17–23
- delivered over multiple contacts (whether it be office visits, telephone, or group sessions)17–23
- contains a written plan to achieve goals.17–23
We do not know what “dose-response” relationship exists for primary care clinician communication with patients over the long term, and what effect repeated counseling would have on long-term sustainability of physical activity levels. This is even less clear for underserved groups.
It is also unknown to what extent collaborative linkages with community programs might increase physical activity in addition to primary care based counseling. Future research should evaluate the optimal “dose-response,” the effect of repeated visits and continuity of care, and the effect of community based referrals for physical activity programs for underserved populations in primary care.
Limitations of this review
Because our inclusion criteria were strict, we omitted potentially meaningful studies that were less directly relevant to our aims. For example, there has been substantial creative community-based work with underserved populations in the US to promote physical activity, and many innovations have been designed by researchers outside the US. Results from these programs and trials should be incorporated into primary care settings working with underserved populations.
Another limitation is that our definition of “underserved” is not the only possible definition. The most marginalized underserved groups with the least access to the health care system (such as the uninsured or homeless) were more likely to be omitted from our results, because we wanted to examine physical activity programs among patients in primary care settings.
Finally, this review did not address the need to understand the causal pathway between sustained improvements in physical activity and patient oriented health outcomes for underserved populations.