Review
Factors contributing to the effectiveness of physical activity counselling in primary care: A realist systematic review

https://doi.org/10.1016/j.pec.2014.11.020Get rights and content

Highlights

  • Physical activity (PA) counselling in primary care is not consistently practiced.

  • A realist systematic review was conducted to identify optimal design features.

  • Ten studies were eligible but provided limited detail so further research is needed.

  • Single counselling sessions exploring motivation increased PA.

  • Multiple sessions may sustain increased PA beyond 12 months.

Abstract

Objective

Physical activity (PA) counselling in primary care increases PA but is not consistently practiced. This study examined factors that optimise the delivery and impact of PA counselling.

Methods

A realist systematic review based on the PRECEDE–PROCEED model and RAMESES principles was conducted to identify essential components of PA counselling. MEDLINE, EMBASE, Cochrane Library, PsycINFO, and Physical Education Index were searched from 2000 to 2013 for studies that evaluated family practice PA counselling.

Results

Of 1546 articles identified, 10 were eligible for review (3 systematic reviews, 5 randomised controlled trials, 2 observational studies). Counselling provided by clinicians or counsellors alone that explored motivation increased self-reported PA at least 12 months following intervention. Multiple sessions may sustain increased PA beyond 12 months.

Conclusion

Given the paucity of eligible studies and limited detail reported about interventions, further research is needed to establish the optimal design and delivery of PA counselling. Research and planning should consider predisposing, reinforcing and enabling design features identified in these studies.

Practice implications

Since research shows that PA counselling promotes PA but is not widely practiced, primary care providers will require training and tools to operationalize PA counselling.

Introduction

Physical activity (PA) reduces the risk of chronic disease, premature mortality, and health system costs [1], [2], [3], [4], [5], [6]. PA guidelines have been developed worldwide and in Canada, where PA is further promoted with Physical Activity Guides for all ages, the Children's Fitness Tax Credit, and social marketing organizations such as ParticipACTION [7], [8]. However, fitness levels have declined, while obesity and premature mortality have increased in Canada, Europe and the United States over the last 20 years [9], [10], [11], [12]. The World Health Organization reports that physical inactivity is the fourth leading risk factor for global mortality causing an estimated 3.2 million deaths globally [1]. Therefore, it is imperative that additional strategies beyond issuing of guidelines and raising public awareness are identified to encourage PA.

The primary care setting offers a convenient platform in which to promote PA. The majority of Canadians (77%) and Americans (80%) have at least one contact with a primary care physician annually during which discussions about health habits including PA are recommended [13], [14]. Considerable research has shown that counselling more than any other intervention is an effective strategy for PA promotion in primary care [15]. PA counselling refers to advice and discussion about PA among primary care providers and individual patients. PA counselling in the primary care setting appears to be an efficient and effective means of increasing PA [16].

However, surveys of primary care physicians and/or patients report low rates of PA counselling worldwide [17], [18], [19], [20], [21], [22]. Systematic reviews revealed numerous barriers to PA counselling in primary care including lack of time, knowledge, training, materials for learning, education and information, protocols or other system support, resources, incentives and reimbursement [23]. In particular, providers are uncertain about the effectiveness of counselling and uncomfortable providing detailed advice about PA [24]. PA counselling in primary care may have greater impact if providers were able to consistently counsel patients about PA. Systematic reviews already conducted did not examine factors that may have influenced the success of counselling such as the content or delivery of counselling, or of accompanying information or tools. Therefore further research is needed to understand how the design and impact of PA counselling could be optimised. Such information could be used to develop interventions that support PA counselling by primary care providers.

A commonly used model for designing or evaluating health promotion interventions is the PRECEDE–PROCEED model [25]. PRECEDE refers to micro and meso level factors that may influence how an intervention works. Predisposing factors are those that a patient brings to the primary care setting (knowledge, attitudes, beliefs, values, age, health status). Reinforcing factors are those that primary care providers bring to the patient consultation (values, personal physical activity habits, health promotion and counselling practice). Enabling factors may include the availability of resources, protocols and service structures. PROCEED refers to policy or regulatory constructs, and involves implementing and evaluating the impact of selected interventions. The PRECEDE constructs provide a framework for understanding how various factors influence PA counselling and its impact.

The primary purpose of this study was to identify the predisposing, reinforcing and enabling factors that optimise the effectiveness of PA counselling. The findings may provide insight on how to tailor the design, delivery and impact of counselling for PA promotion. That information could be used by policy-makers, educators, professional societies or primary care teams to develop and apply interventions or tools that support counselling for PA promotion in the primary care setting, ultimately leading to improved PA and associated improvements in the physical and mental health of patients.

Section snippets

Approach

A realist systematic review was conducted [26]. This approach is specifically used to describe the theoretical or contextual factors that contribute to the effectiveness of behavioural interventions. It is similar in rigor to a traditional systematic review but draws on a range of study designs to examine the interaction between context, intervention, outcome and underlying theory. RAMESES criteria guided the conduct and reporting of the review [27]. Data were publicly available so

Results

A total of 1546 articles were identified by search strategies across all sources of which 624 were duplicates leaving 922 items to be screened. Of these, 912 were excluded resulting in 10 studies eligible for review (Fig. 1).

Three systematic reviews were eligible, of which two were judged as high and one as medium quality (Table 1). Counselling was brief in two studies that reported session length. Self-reported PA increased at 12 months in two studies [31], [32] and at 6 but not 12 months in

Discussion

PA counselling is an intervention that could be widely replicated and reach many individuals if we learned how to successfully do so. The purpose of this realist review was to identify the predisposing, reinforcing and enabling factors that optimise the effectiveness of primary care PA counselling. This approach was unique from existing, traditional systematic reviews which found PA counselling to be effective but did not explore factors contributing to effectiveness such that is could be

Funding

This study was undertaken with funding from the Canadian Institutes of Health Research.

Conflict of interest

The authors declare no actual or potential conflicts of interest including any financial, personal or other relationships with other people or organizations within three years of beginning the submitted work that could inappropriately influence, or be perceived to influence, this work.

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