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Integrating Physical Activity in Primary Care Practice

      Abstract

      Based on a collaborative symposium in 2014 hosted by the Society of Behavioral Medicine (SBM) and the American College of Sports Medicine (ACSM), this paper presents a model for physical activity counseling for primary care physicians (PCPs). Most US adults do not meet national recommendations for physical activity levels. Socioecological factors drive differences in physical activity levels by geography, sex, age, and racial/ethnic group. The recent Patient Protection and Affordable Care Act incentivizes PCPs to offer patients physical activity counseling. However, PCPs have reported socioecological barriers to physical activity counseling and also patient barriers to physical activity, spanning from the individual to the environmental (eg, lack of safe spaces for physical activity), policy (eg, reimbursement policies), and organizational (eg, electronic medical record protocols, worksite norms/policies) levels. The aims of this paper are to: 1) discuss barriers to PCP counseling for physical activity; 2) provide evidence-based strategies and techniques to help PCPs address these counseling barriers; and 3) suggest practical steps for PCPs to counsel patients on physical activity using strategies and supports from policy, the primary care team, and other support networks.

      Keywords

      Clinical Significance
      • There are high rates of physical inactivity in the general population.
      • Disparities exist in physical activity rates by race/ethnicity, sex, age, and region.
      • The primary care setting is ideal for physical activity counseling.
      • A multilevel approach helps physicians to provide physical activity counseling.
      About half (49.6%) of US adults met the most recent (2008) Centers for Disease Control and Prevention's Physical Activity Guidelines of at least 150 minutes weekly of moderate- or vigorous-intensity aerobic physical activity.
      • Barnes P.
      • Ward B.
      • Freeman G.
      • Schiller J.
      Early release of selected estimates based on data from the January-September 2010 National Health Interview Survey.
      Even fewer adults met the recommendations for strength training activities on 2 or more days of the week (23.6% in 2012), and fewer still fulfilled both recommendations (20.3% in 2012). Disparities in physical activity exist by socioecologic levels (ie, individual, social, and environmental levels of influence on behavior), including geography, sex, age, and racial/ethnic group. Physical activity rates are disproportionately lower among rural vs urban residents, residents of the southwestern region of the US vs other regions, women vs men, older vs younger, and racial and ethnic minorities vs non-Hispanic whites.
      • Pratt M.
      • Macera C.A.
      • Blanton C.
      Levels of physical activity and inactivity in children and adults in the United States: current evidence and research issues.
      • Taylor W.C.
      • Floyd M.F.
      • Whitt-Glover M.C.
      • Brooks J.
      Environmental justice: a framework for collaboration between the public health and parks and recreation fields to study disparities in physical activity.
      These disparities in physical activity underscore the importance of incorporating patient socioecologic contexts, including their families, work, health care systems, and neighborhoods, in physical activity counseling.
      • Taylor W.C.
      • Floyd M.F.
      • Whitt-Glover M.C.
      • Brooks J.
      Environmental justice: a framework for collaboration between the public health and parks and recreation fields to study disparities in physical activity.
      • Hallal P.C.
      • Andersen L.B.
      • Bull F.C.
      • et al.
      Global physical activity levels: surveillance progress, pitfalls, and prospects.
      The recent Patient Protection and Affordable Care Act (ACA) has incentivized physical activity counseling by primary care physicians (PCPs).

      An act entitled The Patient Protection and Affordable Care Act, 119 42, §18001 (2010).

      Physical activity can be promoted at multiple levels as described above. Given the inherent trust that patients have in their PCPs, the PCP can play a central role in delivering effective physical activity interventions. In 2015, an editorial by Berra et al
      • Berra K.
      • Rippe J.
      • Manson J.E.
      Making physical activity counseling a priority in clinical practice: the time for action is now.
      reiterated the overall message from a 2004 editorial by Blair and Church,
      • Blair S.N.
      • Church T.S.
      The fitness, obesity, and health equation: is physical activity the common denominator?.
      which declared, “… Just as weight is addressed in some manner at nearly every physician visit, so should attention be given to recommending the accumulation of 30 minutes a day of moderate-intensity physical activity at least 5 days of the week.” This paper will assist the role of PCPs in taking advantage of recent ACA incentives to promote physical activity by providing a step-by-step guide to physical activity counseling that addresses socioecological barriers to the uptake of regular and sustained physical activity and leverages community resources that promote and support physical activity.
      Despite evidence for the cost-effectiveness of physical activity counseling in primary care,
      • Garrett S.
      • Elley C.R.
      • Rose S.B.
      • O'Dea D.
      • Lawton B.A.
      • Dowell A.C.
      Are physical activity interventions in primary care and the community cost-effective? A systematic review of the evidence.
      only one-third of patients report the receipt of physical activity counseling by their PCPs.
      • Dacey M.L.
      • Kennedy M.A.
      • Polak R.
      • Phillips E.M.
      Physical activity counseling in medical school education: a systematic review.
      • Tulloch H.
      • Fortier M.
      • Hogg W.
      Physical activity counseling in primary care: who has and who should be counseling?.
      PCPs face many barriers to counseling their patients on physical activity, primarily due to time limitations, especially when trying to address multiple or complex medical issues. PCPs address an average of 3 medical issues per patient visit, with slightly higher averages for elderly and diabetic patients.
      • Bodenheimer T.
      • Chen E.
      • Bennett H.D.
      Confronting the growing burden of chronic disease: can the U.S. health care workforce do the job?.
      However, PCPs are in a unique position to provide physical activity counseling because of their ability to reach a large segment of the overall population, their role as a trusted source of health information, and the range of other health professionals available within clinics.
      • Estabrooks P.A.
      • Glasgow R.E.
      • Dzewaltowski D.A.
      Physical activity promotion through primary care.
      • Estabrooks P.A.
      • Glasgow R.E.
      Translating effective clinic-based physical activity interventions into practice.
      A multilevel socioecologic approach
      • Stokols D.
      Translating social ecological theory into guidelines for community health promotion.
      • Stokols D.
      • Allen J.
      • Bellingham R.L.
      The social ecology of health promotion: implications for research and practice.
      • Stokols D.
      Social ecology and behavioral medicine: implications for training, practice, and policy.
      • Stokols D.
      Establishing and maintaining healthy environments. Toward a social ecology of health promotion.
      to physical activity counseling can be centered in the primary care setting, as the PCP could provide a “prescription” (or brief advice) for physical activity to help ready the patient for making changes in their current levels or type of physical activity.
      • Grandes G.
      • Sanchez A.
      • Sanchez-Pinilla R.O.
      • et al.
      Effectiveness of physical activity advice and prescription by physicians in routine primary care: a cluster randomized trial.
      The socioecologic approach can be integrated with the well-known physical activity counseling approach using the 5As—assess, advise, agree, assist, and arrange—a mnemonic that describes a sequence of counseling behaviors that are meant to engage the patient in developing a specific, safe, and realistic action plan for behavior change.
      • Estabrooks P.A.
      • Glasgow R.E.
      • Dzewaltowski D.A.
      Physical activity promotion through primary care.
      The 5As have been used with success for tobacco cessation.
      • Quinn V.P.
      • Hollis J.F.
      • Smith K.S.
      • et al.
      Effectiveness of the 5-As tobacco cessation treatments in nine HMOs.
      Further, some evidence suggests that physical activity counseling is more effective when delivered by trained counselors, to whom the provider could refer.
      • Tulloch H.
      • Fortier M.
      • Hogg W.
      Physical activity counseling in primary care: who has and who should be counseling?.
      • Balasubramanian B.A.
      • Cohen D.J.
      • Clark E.C.
      • et al.
      Practice-level approaches for behavioral counseling and patient health behaviors.
      • Beall R.F.
      • Baskerville N.
      • Golfam M.
      • Saeed S.
      • Little J.
      Modes of delivery in preventive intervention studies: a rapid review.
      • Eakin E.G.
      • Glasgow R.E.
      • Riley K.M.
      Review of primary care-based physical activity intervention studies: effectiveness and implications for practice and future research.
      The PCP's time is also used more efficiently by connecting to resources within the practice, particularly among fellow primary care team members. This approach, combined with basic self-monitoring (eg, wearable tracking devices or paper journals), community resources, and follow-up with the PCP, can enhance motivation and increase self-awareness.
      • Aittasalo M.
      • Miilunpalo S.
      • Kukkonen-Harjula K.
      • Pasanen M.
      A randomized intervention of physical activity promotion and patient self-monitoring in primary health care.
      External resources like these may be more likely to be accepted if they are suggested by the PCP, because patients tend to trust their PCPs the most for health information.
      • Grandes G.
      • Sanchez A.
      • Sanchez-Pinilla R.O.
      • et al.
      Effectiveness of physical activity advice and prescription by physicians in routine primary care: a cluster randomized trial.
      PCPs lack a practical approach to overcoming barriers to physical activity counseling, which may be available by leveraging clinical and community resources. The aims of this paper are to: 1) discuss barriers to PCP counseling for physical activity; 2) provide a multilevel approach using evidence-based strategies and techniques to help PCPs address counseling barriers; and 3) suggest practical steps for PCPs to counsel patients on physical activity.

      Evidence for the Effectiveness of Physical Activity Interventions in Primary Care

      Findings on the impact of physical activity interventions in primary care have been mixed, due to insufficient follow-up or a lack of clarity about intervention intensity.
      • Eden K.B.
      • Orleans C.T.
      • Mulrow C.D.
      • Pender N.J.
      • Teutsch S.M.
      Does counseling by clinicians improve physical activity? A summary of the evidence for the U.S. Preventive Services Task Force.
      • Marcus B.H.
      • Williams D.M.
      • Dubbert P.M.
      • et al.
      Physical activity intervention studies: what we know and what we need to know: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity); Council on Cardiovascular Disease in the Young; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research.
      Heath et al (2012)
      • Heath G.W.
      • Parra D.C.
      • Sarmiento O.L.
      • et al.
      Evidence-based intervention in physical activity: lessons from around the world.
      examined systematic reviews of evidence-based physical activity interventions, which found that more effective interventions addressed multiple levels of change, including the individual, social, and environmental levels. Given the power of a PCP's prescription for physical activity, and the importance of multiple levels of supportive resources, the integration of a multilevel approach to physical activity counseling within primary care has the potential to favorably impact patient physical activity levels.
      • Heath G.W.
      • Parra D.C.
      • Sarmiento O.L.
      • et al.
      Evidence-based intervention in physical activity: lessons from around the world.

      Barriers to Implementing Physical Activity Counseling in Primary Care

      PCPs face significant challenges to physical activity counseling. Major provider barriers to physical activity counseling include limited time, skills, reimbursement, reach, and routine screening for physical activity.

      Lack of Provider Time

      One of the primary barriers to physical activity counseling in primary practice is the lack of adequate time to effectively counsel patients. Patient visits are typically brief and often cover multiple health concerns.
      • Lewis K.H.
      • Gudzune K.A.
      Overcoming challenges to obesity counseling: suggestions for the primary care provider.
      A recent study on the effectiveness of using the 5As for physical activity counseling reported a minimal impact on the overall length of visits (83% spent <5 to 6 minutes on physical activity counseling).
      • Albright C.L.
      • Cohen S.
      • Gibbons L.
      • et al.
      Incorporating physical activity advice into primary care: physician-delivered advice within the activity counseling trial.
      Further, the combination of initial brief counseling with the physician can be enhanced by referrals to other resources, as discussed in a later section, because effective physical activity counseling requires regular follow-up visits or contacts.
      • Tulloch H.
      • Fortier M.
      • Hogg W.
      Physical activity counseling in primary care: who has and who should be counseling?.

      Lack of Provider Skills

      PCPs often lack the training and skills to provide effective physical activity counseling.
      • Tulloch H.
      • Fortier M.
      • Hogg W.
      Physical activity counseling in primary care: who has and who should be counseling?.
      • Lewis K.H.
      • Gudzune K.A.
      Overcoming challenges to obesity counseling: suggestions for the primary care provider.
      A recent study estimated that only 10 medical school programs provide training on physical activity, although program content is unstandardized.
      • Dacey M.L.
      • Kennedy M.A.
      • Polak R.
      • Phillips E.M.
      Physical activity counseling in medical school education: a systematic review.
      Because patients tend to place the most trust in health information from their PCPs, and a PCP prescription for physical activity has been found effective in increasing patient exercise, PCPs initiating the conversation with patients may have great impact on their physical activity levels.
      • Grandes G.
      • Sanchez A.
      • Sanchez-Pinilla R.O.
      • et al.
      Effectiveness of physical activity advice and prescription by physicians in routine primary care: a cluster randomized trial.

      Cost/Lack of Provider Reimbursement

      Despite the recent recommendation by the US Preventive Services Task Force for routine obesity screening, reimbursement still poses a significant obstacle to routine primary care screening and counseling for obesity, of which physical inactivity is a major contributor. Although the Centers for Medicare and Medicaid Services now offers coverage for obesity counseling, it must be provided on-site and by high-level primary care providers (ie, physicians, nurse practitioners, or physician assistants). This coverage excludes services provided by other trained health care professionals as well as services provided by phone or in a community setting. This exclusion applies despite evidence that patients have improved their physical activity levels with trained nonphysician providers, sometimes with even greater results.
      • Tulloch H.
      • Fortier M.
      • Hogg W.
      Physical activity counseling in primary care: who has and who should be counseling?.
      • Balasubramanian B.A.
      • Cohen D.J.
      • Clark E.C.
      • et al.
      Practice-level approaches for behavioral counseling and patient health behaviors.
      • Beall R.F.
      • Baskerville N.
      • Golfam M.
      • Saeed S.
      • Little J.
      Modes of delivery in preventive intervention studies: a rapid review.
      • Eakin E.G.
      • Glasgow R.E.
      • Riley K.M.
      Review of primary care-based physical activity intervention studies: effectiveness and implications for practice and future research.
      The lack of reimbursement for physical activity counseling for nonobese patients who are not necessarily seeking weight loss is a further challenge because physical activity is important regardless of weight status. Due to some ongoing challenges with reimbursement, it may be cost-effective to incorporate community referrals and other resources to supplement provider counseling.
      • Garrett S.
      • Elley C.R.
      • Rose S.B.
      • O'Dea D.
      • Lawton B.A.
      • Dowell A.C.
      Are physical activity interventions in primary care and the community cost-effective? A systematic review of the evidence.
      • Pavey T.G.
      • Taylor A.H.
      • Fox K.R.
      • et al.
      Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis.

      Lack of Provider Reach to At-Risk Patients

      Primary care practices are considered an ideal location for preventive services such as physical activity counseling because of the provider's ability to potentially reach broad segments of the population through patient visits. With Accountable Care Organizations, providers are responsible for a panel of patients, both those seen in the office and those not. By integrating community resources into primary care physical activity counseling, providers are able to also potentially reach individuals who do not regularly seek primary care.

      Lack of Routine Patient Screening for Physical Activity in Primary Care Practices

      Physical activity screening is the first part of physical activity counseling, so incorporating routine physical activity screening in primary care would create an opportunity for PCPs to provide physical activity counseling. Moreover, the routinization of physical activity screening will help patients to then see how physical activity is an important indicator of health. The National Physical Activity Plan supports prioritizing the addition of physical activity as a vital sign, but routine physical activity screening is rare in actual practice.
      • Joy E.L.
      • Blair S.N.
      • McBride P.
      • Sallis R.
      Physical activity counselling in sports medicine: a call to action.
      • Lobelo F.
      • Stoutenberg M.
      • Hutber A.
      The Exercise is Medicine Global Health Initiative: a 2014 update.
      Only a few organizations, such as Kaiser Permanente, currently screen all patients for their participation in physical activity.
      • Sallis R.
      Developing healthcare systems to support exercise: exercise as the fifth vital sign.
      The first A of the 5As counseling framework incorporates regular physical activity screening and charting, alongside the other vitals during the same office visit.

      Patient Barriers to Physical Activity

      Counseling patients about physical activity may reveal a number of barriers to physical activity, including limited time, fatigue, family obligations (especially for caregivers), or other competing priorities.
      • Wilcox S.
      • Castro C.
      • King A.C.
      • Housemann R.
      • Brownson R.C.
      Determinants of leisure time physical activity in rural compared with urban older and ethnically diverse women in the United States.
      They may be hesitant to try to increase their physical activity if they think that it will be too much of a time commitment,
      • Burton N.W.
      • Turrell G.
      Occupation, hours worked, and leisure-time physical activity.
      • Reichert F.F.
      • Barros A.J.
      • Domingues M.R.
      • Hallal P.C.
      The role of perceived personal barriers to engagement in leisure-time physical activity.
      if they lack safe paths or open spaces for activity away from traffic or gangs,
      • Powell L.M.
      • Slater S.
      • Chaloupka F.J.
      • Harper D.
      Availability of physical activity-related facilities and neighborhood demographic and socioeconomic characteristics: a national study.
      or if gyms are too far to get to or costly.
      • Estabrooks P.A.
      • Glasgow R.E.
      • Dzewaltowski D.A.
      Physical activity promotion through primary care.
      Patients may also find it difficult to be active if they live in areas where they don't see others being active, feel self-conscious about being active, or do not enjoy physical activities alone.
      • Wilcox S.
      • Castro C.
      • King A.C.
      • Housemann R.
      • Brownson R.C.
      Determinants of leisure time physical activity in rural compared with urban older and ethnically diverse women in the United States.
      • Reichert F.F.
      • Barros A.J.
      • Domingues M.R.
      • Hallal P.C.
      The role of perceived personal barriers to engagement in leisure-time physical activity.
      The following section describes resources to help address each of these patient barriers to physical activity.

      Multilevel Approaches to Overcome Barriers to Physical Activity and Physical Activity Counseling

      Interventions at multiple levels of the socioecological framework can help to overcome many of the barriers described above, namely provider time and training. The PCP and the primary care team can serve as the hub for physical activity counseling, while resources at other levels (eg, policy, organizations, community) can help patients to enact and sustain changes in physical activity. The following sections describe how providers might utilize these different resources (Table) as well as how they might be incorporated into counseling (Figure).
      TableMultilevel Supports to Address Barriers to Physical Activity Interventions
      BarriersSupports
      OrganizationsPolicy
      • Primary care practices (insufficient cost/reimbursement for physical activity counseling)
      • Community-based organizations and worksites (insufficient prioritizing of physical activity resources)
      • PPACA (mandate for physical activity counseling)
      • EIM (promote routine physical activity screening)
      • Let's Move (changing social norms)
      • Rx2Move (resources for providers)
      ProviderOrganizations
      • Insufficient time
      • Insufficient training
      • Team-based care
      • Routine physical activity screening
      • Team-based care
      • Community referrals
      • 5As counseling
      PatientCommunity
      • Insufficient time
      • Insufficient resources
      • Insufficient social support
      • Resources (low-cost physical activity opportunities in the community, physical activity monitoring devices, etc.)
      • Social support (community groups, online groups)
      EIM = Exercise is Medicine; PPACA = Patient Protection and Affordable Care Act.
      Figure thumbnail gr1
      FigureHow to use the 5As in physical activity counseling.

      Primary Care Practice Organizations

      Within primary care practices, physical activity screening is the simplest way to begin a conversation about the importance of physical activity (regardless of weight status) by asking patients about their current physical activity levels. This is especially beneficial to providers who may not otherwise be comfortable initiating this conversation with the patient. Additionally, standardizing the inclusion of physical activity screening with each visit can help to emphasize the important relationship between physical activity and health for patients. The MOHR (My Own Health Record) project is an example of how to use routine physical activity screening in primary care to increase physical activity screening, goal setting, and patient perception of improvement.
      • Krist A.H.
      • Glenn B.A.
      • Glasgow R.E.
      • et al.
      Designing a valid randomized pragmatic primary care implementation trial: the my own health report (MOHR) project.
      Another example of how to implement practice-wide changes to increase patient physical activity levels is Move More, a multilevel physical activity intervention that combines clinic staff, participant group meetings, and health policy changes.
      • Estabrooks P.A.
      • Smith-Ray R.L.
      • Almeida F.A.
      • et al.
      Move More: translating an efficacious group dynamics physical activity intervention into effective clinical practice.
      Kaiser Permanente's Rx2Move campaign notes that the screening process takes less than a minute.

      Kaiser Permanente Institute Staff. A prescription to move (#Rx2Move) – how health care providers can encourage physical activity for patients and communities. Available at: www.kpihp.org/rx2move/. Accessed March 10, 2016.

      Primary Care Teams

      Given the limited time that providers have with patients, the use of primary care teams may reduce individual burden and expand the range of expertise available to each patient for physical activity counseling. Depending on available resources, team members can leverage existing chronic disease management programs and well visits, especially with the increased use of patient-centered medical home approaches to patient care.
      • Stange K.C.
      • Nutting P.A.
      • Miller W.L.
      • et al.
      Defining and measuring the patient-centered medical home.
      For example, PCPs may work in tandem with other primary care team members so that the nurse practitioner may administer the routine physical activity screening, the PCP may write the prescription to exercise, the exercise physiologist or trainer may create an individualized exercise plan, and the behavioral counselor may follow up with the patient and refer him/her to local physical activity resources, depending on patient readiness to exercise and preferred forms of physical activity.
      • Tulloch H.
      • Fortier M.
      • Hogg W.
      Physical activity counseling in primary care: who has and who should be counseling?.
      • Eakin E.G.
      • Glasgow R.E.
      • Riley K.M.
      Review of primary care-based physical activity intervention studies: effectiveness and implications for practice and future research.
      PCP-based physical activity counseling may be more effective when combined with follow-up and community support; short-term benefits are seen when patients receive follow-up phone calls about progress and supplementary written materials.
      • Eakin E.G.
      • Glasgow R.E.
      • Riley K.M.
      Review of primary care-based physical activity intervention studies: effectiveness and implications for practice and future research.

      Individuals

      PCPs may also want to discuss physical activity monitoring with patients, especially given the growing popularity of, and advances in, wearable technology.
      • Ferguson T.
      • Rowlands A.V.
      • Olds T.
      • Maher C.
      The validity of consumer-level, activity monitors in healthy adults worn in free-living conditions: a cross-sectional study.
      • Cadmus-Bertram L.A.
      • Marcus B.H.
      • Patterson R.E.
      • Parker B.A.
      • Morey B.L.
      Randomized trial of a Fitbit-based physical activity intervention for women.
      • Ramirez E.R.
      • Peterson C.
      • Wu W.
      • Norman G.J.
      Accuracy of the FitBit Pedometer for self-paced and prescribed physical activity.
      Self-monitoring can help patients to assess their current level of physical activity and facilitate goal setting to increase their levels of physical activity. Physical activity self-monitoring tools range from basic pedometers to smartphone apps to wearable devices that can also monitor sleep and heart rate.
      • Coleman A.
      Fitabase comes out of beta with same day support for Fitbit heart rate models.
      • Blackman K.C.
      • Zoellner J.
      • Berrey L.M.
      • et al.
      Assessing the internal and external validity of mobile health physical activity promotion interventions: a systematic literature review using the RE-AIM framework.
      A reported 82% of Americans have a cell phone,
      • Handel D.A.
      • Wears R.L.
      • Nathanson L.A.
      • Pines J.M.
      Using information technology to improve the quality and safety of emergency care.
      which provides multiple opportunities to communicate with others about physical activity, search for medical advice, and monitor personal health information.
      • Klasnja P.
      • Pratt W.
      Healthcare in the pocket: mapping the space of mobile-phone health interventions.
      This can reduce the amount of face-to-face time required for patient monitoring
      • Beall R.F.
      • Baskerville N.
      • Golfam M.
      • Saeed S.
      • Little J.
      Modes of delivery in preventive intervention studies: a rapid review.
      and facilitate patient–provider communication about physical activity. These devices also provide immediate feedback about patients' physical activity levels, supporting their self-regulation of their physical activity behaviors,
      • Turner-McGrievy G.M.
      • Beets M.W.
      • Moore J.B.
      • Kaczynski A.T.
      • Barr-Anderson D.J.
      • Tate D.F.
      Comparison of traditional versus mobile app self-monitoring of physical activity and dietary intake among overweight adults participating in an mHealth weight loss program.
      and can also connect patients to online communities for support.

      Support Systems of Families, Friends, and Co-Workers and Others

      As part of the physical activity counseling, the PCP can ask about the patient's support system and how that might impact any new physical activity habits. This support system (eg, family, friends, co-workers, and others) might be supportive of new physical activity habits (eg, joining the patient in new activities, providing childcare to give the patient time for exercise) or discouraging (eg, complaining that physical activity takes away from family time).
      • Treiber F.A.
      • Baranowski T.
      • Braden D.S.
      • Strong W.B.
      • Levy M.
      • Knox W.
      Social support for exercise: relationship to physical activity in young adults.
      • Resnick B.
      • Orwig D.
      • Magaziner J.
      • Wynne C.
      The effect of social support on exercise behavior in older adults.
      • Eyler A.A.
      • Brownson R.C.
      • Donatelle R.J.
      • King A.C.
      • Brown D.
      • Sallis J.F.
      Physical activity social support and middle- and older-aged minority women: results from a US survey.
      For individuals without a local support system or with unsupportive friends and family, virtual support groups available through fitness Web sites, apps, and forums are increasingly popular.
      • Pagoto S.L.
      • Schneider K.L.
      • Oleski J.
      • Smith B.
      • Bauman M.
      The adoption and spread of a core-strengthening exercise through an online social network.
      These support systems enable the patient and his/her supports to challenge and motivate each other to make and adhere to physical activity-related goals.
      • Sherwood N.E.
      • Jeffery R.W.
      The behavioral determinants of exercise: implications for physical activity interventions.

      Local Community Resources

      PCPs can identify relevant community resources for their patients via their local health department, local health-focused community organizations, and campaigns from national organizations such as the American College of Sports Medicine's global initiative Exercise is Medicine (EIM)

      Exercise is Medicine. Home page. Available at: www.exerciseismedicine.org. Accessed March 10, 2016.

      and Kaiser Permanente's Rx2Move.

      Kaiser Permanente Institute Staff. A prescription to move (#Rx2Move) – how health care providers can encourage physical activity for patients and communities. Available at: www.kpihp.org/rx2move/. Accessed March 10, 2016.

      Community-wide initiatives (eg, walk-a-thons or weight loss challenges) have increased physical activity across entire communities.
      • Kahn E.B.
      • Ramsey L.T.
      • Brownson R.C.
      • et al.
      The effectiveness of interventions to increase physical activity. A systematic review.
      • Estabrooks P.A.
      • Bradshaw M.
      • Dzewaltowski D.A.
      • Smith-Ray R.L.
      Determining the impact of Walk Kansas: applying a team-building approach to community physical activity promotion.
      In addition, local parks, civic organizations, adult schools, community colleges, or other community groups (eg, YMCAs, Silver Sneakers) may offer free or low-cost activities and classes for adults, led by community members. A primary care team member, such as a medical assistant, may be interested in compiling local resources for providers to then refer patients. Community resources capitalize on existing social networks to support individual health behavior changes
      • McNeill L.H.
      • Kreuter M.W.
      • Subramanian S.V.
      Social environment and physical activity: a review of concepts and evidence.
      and may also address unique patient barriers, such as the need for safe spaces or child care.
      • Estabrooks P.A.
      • Bradshaw M.
      • Dzewaltowski D.A.
      • Smith-Ray R.L.
      Determining the impact of Walk Kansas: applying a team-building approach to community physical activity promotion.
      • Smith-Ray R.L.
      • Mama S.
      • Reese-Smith J.Y.
      • Estabrooks P.A.
      • Lee R.E.
      Improving participation rates for women of color in health research: the role of group cohesion.
      • Ackermann R.T.
      • Marrero D.G.
      Adapting the Diabetes Prevention Program lifestyle intervention for delivery in the community: the YMCA model.
      Provider endorsements can help to lend legitimacy to these programs to increase patient uptake.

      Worksites

      PCPs may also suggest that patients use physical activity resources provided at work. Adults in the US now spend a large portion of their time at the workplace, so workplace interventions may reduce time- or location-based barriers to increasing daily physical activity. Workplace resources may include: standing or treadmill desks, walking meetings, brief activity breaks during long meetings, walking during lunch breaks, workplace-sponsored activity classes (eg, yoga), and prompts to use the stairs instead of the elevator.
      • Conn V.S.
      • Hafdahl A.R.
      • Cooper P.S.
      • Brown L.M.
      • Lusk S.L.
      Meta-analysis of workplace physical activity interventions.
      Some workplaces may allow extended lunch breaks, flexible work hours, or discounted gym memberships in order to facilitate their employees' abilities to exercise prior to, during, or after work without adding extra transit time or expenses associated with off-site gym memberships.
      • Yancey A.K.
      • Sallis R.E.
      • Bastani R.
      Changing physical activity participation for the medical profession.
      • Lara A.
      • Yancey A.K.
      • Tapia-Conye R.
      • et al.
      Pausa para tu Salud: reduction of weight and waistlines by integrating exercise breaks into workplace organizational routine.
      • Pratt C.A.
      • Lemon S.C.
      • Fernandez I.D.
      • et al.
      Design characteristics of worksite environmental interventions for obesity prevention.

      National Health Care Organizations

      As mentioned earlier, EIM promotes a standardized approach to systematically assess and prescribe physical activity to patients.
      • Lobelo F.
      • Stoutenberg M.
      • Hutber A.
      The Exercise is Medicine Global Health Initiative: a 2014 update.
      • Sallis R.
      Exercise is medicine: a call to action for physicians to assess and prescribe exercise.
      Early EIM pilot work has indicated that physical activity screening is best used when integrated into the electronic medical records system as a required response (G.W. Heath, unpublished data, 2014). In the US, anecdotal evidence suggests that EIM-involved PCPs have other team members assess patient physical activity, while PCPs in countries with longer office visits tend to assess the patients themselves. EIM has provided credentialed exercise professionals for community referrals, which could contribute to standard, higher-quality physical activity care.

      Health Policies

      Policy-based interventions can support PCP efforts to counsel patients about physical activity. For example, the ACA requires employer-sponsored group health plans and private health insurance policies to cover preventive health services without cost sharing.
      • Berra K.
      • Rippe J.
      • Manson J.E.
      Making physical activity counseling a priority in clinical practice: the time for action is now.
      On a national level, Michelle Obama and the Partnership for a Healthier America have established Let's Move! to promote physical activity among children and their caregivers, which has led to branded physical activity challenges and informational videos that are easily accessible and shared through social media (eg, YouTube).
      • Wojcicki J.M.
      • Heyman M.B.
      Let's Move—childhood obesity prevention from pregnancy and infancy onward.

      PCP Approach to Multilevel Physical Activity Counseling Using the 5As

      We have described various multilevel strategies and supports for patients to increase their physical activity. The PCP is key to this multilevel approach, using the 5As to guide the conversation from the initial assessment of current physical activity levels through arranging follow-ups to assess physical activity (see the Figure for sample dialogue).

      An act entitled The Patient Protection and Affordable Care Act, 119 42, §18001 (2010).

      Studies indicate that most counseling sessions focus on the first 2 As (assess physical activity levels, advise about increasing physical activity) while not addressing the last 3 As (agree on physical activity goals, assist with connecting patients with physical activity resources, arrange for follow-ups about physical activity).
      • Alexander S.C.
      • Cox M.E.
      • Boling Turer C.L.
      • et al.
      Do the five A's work when physicians counsel about weight loss?.
      This finding has been attributable primarily to the PCP and organizational barriers previously mentioned. The multilevel approach to physical activity counseling as described in this paper could help to reduce these barriers (Table).

      Discussion and Conclusions

      Despite the numerous barriers that patients face with increasing physical activity, and providers face with counseling patients about physical activity, taking a multilevel approach can help increase supports for routinizing physical activity among patients. The Centers for Medicare and Medicaid Services now provides some reimbursement for on-site physical activity counseling by physicians and other high-level providers. With system-wide structural supports, such as electronic medical records or routine physical activity screening, discussions about physical activity will be more easily integrated into patient visits. With increased PCP awareness of community resources for physical activity, patients can be referred to widely available exercise classes and support groups that are low cost for both patients and provider organizations. Worksites may provide wellness programs, social support for physical activity, and opportunities for physical activity throughout the day. Primary care teams can work together to integrate physical activity into routine care at the initial and follow-up visits. Patient supports, such as the use of self-monitoring devices or community resources, can help guide the patient–provider conversations about physical activity and how patients can increase their physical activity with the support of their family/friends and co-workers.
      The PCP plays a central role in this multilevel approach to physical activity counseling, from helping patients to understand the importance of physical activity to connecting them with various resources for physical activity. Using the range of supports for physical activity available at each of these socioecological levels can help to increase physical activity counseling in primary care, increase physical activity by patients, and sustain these positive behaviors.

      Acknowledgment

      The authors would like to thank Elizabeth A. Joy for her contributions to the development of this manuscript.

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