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219
Understanding and Promoting Physical Activity
Intervention
Findings and comments
I-1:Self-monitoring of attendance, fitness exam
I-1 had better attendance than I-2 overall; interest in self-
I-2:Self-monitoring, staff attention, fitness exam
monitoring waned after 4 weeks
C: Fitness exam
I-1:Self-monitoring, telephone contact, vigorous
Better exercise adherence at 1 year in home-based groups; at
exercise at home
year 2 better adherence in vigorous home-based group; 5
I-2:Self-monitoring, telephone contact, moderate
times per week schedule may have been difficult to follow
exercise at home
I-3:Self-monitoring, vigorous exercise in group
I-1:Weekly calls, general inquiry
Frequent call conditions had 63% walking compared with
I-2:Weekly calls, structured inquiry
26% and 22% in the infrequent condition; frequent call and
I-3:Call every 3 weeks, general inquiry
structured inquiry had higher rate of walking than other
I-4:Call every 3 weeks, structured inquiry
groups
I-1:Mail-delivered lifestyle packet based on
No difference in stage of change status among or
stages of change
within groups
I-2:Mail-delivered structured exercise packet
with exercise prescription
C: Mail-delivered fitness feedback packet
I: Exercise class and relapse prevention training
Higher attendance in relapse prevention group over 10
C: Exercise class
weeks and at 3 months; high attrition and inconsistent
results across experimental groups
I-1:Vigorous self-directed exercise, staff telephone
Better adherence in the moderate-intensity group at 12 weeks
calls, self-monitoring
compared with vigorous (96% vs. 90%) (no statistical tests
I-2:Moderate self-directed exercise, staff
reported); travel, work schedule conflicts, and weather
telephone calls, self-monitoring
were noted as barriers to physical activity
C: Staff telephone calls
I: 90-minute classes 2 times/week after work,
Twofold increase in bouts of exercise compared with
parcourse, self-monitoring, contests
nonparticipants. Participants different from nonparticipants
C: None
at baseline
I-1:Team building, relapse prevention training;
I-2 and I-3 had twice the jogging episodes as I-1 and C at
group exercise
5 weeks; at 3 months, 83% of I-3 were jogging compared
I-2:Team building, group exercise
with 38% of I-1 and I-2 and 36% of C
I-3:Relapse prevention training and jogging alone
C: Jogging alone
I-1:Home-based moderate exercise, self-
No difference in number of sessions and duration reported
monitoring with portable monitor, relapse
at 6-month follow-up
prevention training, telephone calls from staff
I-2:Same as I-1 without telephone calls from staff
I-1:Daily self-monitoring
I-1 had more exercise bouts per month  (11 vs. 7.5)
I-2:Weekly self-monitoring
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220
Physical Activity and Health
Table 6-2.
Continued
Study
Design
Theoretical approach
Population
Marcus and Stanton
18 week
Relapse prevention,
120 female university
(1993)
experimental
social learning
employees, mean
theory
age = 35
McAuley et al. (1994)
5 month
Social learning theory
114 sedentary middle-
experimental
aged adults
Owen et al. (1987)
12 week
Behavioral management
343 white-collar and pro-
quasi-experimental
fessional workers, mean
age = 36, mostly women
Robison et al. (1992)
6 month
Behavioral management,
137 university staff at
quasi-experimental
social support
6 campus worksites,
mean age = 40
Interventions in health care settings
Logsdon, Lazaro,
1 year
None mentioned
2,218 patients from multi-
Meier (1989)
quasi-experimental
specialty group practice
(INSURE)
sites
Calfas et al.
2 week
Stage of change
212 patients
(in press)
quasi-experimental
Community approaches
Luepker et al. (1994)
5 to 6 year
Diffusion of innovations,
Community longitudinal
(Minnesota Heart
quasi-experimental;
social learning theory,
cohort (n = 7,097),
Health Project)
3 matchedpairs
community organization,
independent survey
communication theory
(n = 300–500)
Young et al.
7 year
Social learning theory,
2 sets of paired, medium-
(in press)
quasi-experimental
communication theory,
sized cities (5th city used
(Stanford Five-City Project)
community organization
for surveillance only)
Macera et al. (1995)
4 year
None specified
Community residents
quasi-experimental
‡ 18 years;
(2 matched communities)
24% African American (I),
35% African American (C)
Brownson et al. (1996)
4 year
Social learning theory,
Rural communities; largely
quasi-experimental
stage theory of innovation
African American
I = intervention; C = control or comparison group.
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221
Understanding and Promoting Physical Activity
Intervention
Findings and comments
I-1:Relapse prevention training and exercise
Better attendance in I-1 at 9 weeks; no difference at
I-2:Scheduled reinforcement for attendance
18 weeks or 2-month follow-up
and exercise
C: Exercise only
I: Modeling of exercise, provision of efficacy-
Better class attendance (67% vs. 55%) and more minutes
based information (mastery accomplishments,
and miles walked among intervention group than controls
social modeling, social persuasion,
physiological response), walking program
C: Biweekly meetings on health information,
walking program
I: Self-management instruction, exercise class
No difference in activity levels at 6 months
C: Exercise class
I: Weekly group meetings, contracts, cash
Higher attendance among experimental groups than
incentives, social support, exercise
comparison groups (93–99% vs. 19%)
C: Exercise, diary
I: Screening and counseling from physicians
Increase in starting to exercise among intervention patients
who received continuing education; preventive e (34% to 24%)
visits at no charge
I: Physician counseling; booster call from
Intervention patients increased walking (37 minutes vs.
a health educator
10 minutes per week)
C: Nothing
I: Screening and education; mass media; com-
Percent physically active higher in independent survey at
munity participation; environmental change;
3 years; higher in the cohort at 7 years
professional education; youth and adults
C: Nothing
I: Print materials; workshops and seminars;
Men increased participation in vigorous activities;
organized walking; organized walking events;
men and women in the intervention communities
“Heart & Sole” groups; worksite programs;
increased their overall number of physical activities;
TV spots
significant differences between intervention and
comparison communities at baseline
I: Community cardiovascular risk reduction
No difference in physical activity prevalence, physican
activities
counseling for exercise, or exercise knowledge
C: None specified
I: Community organization; development of 6 coa- - Increased physical activity levels in coalition communities,
litions; exercise classes and walking classes and
declining levels in communities without; net effect was 7%.
walking clubs; demonstrations; sermons; news-
Planned Approach to Community Health education planning
paper articles; community improvements; $5,000 0 model
to each coalition from the state health department
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222
Physical Activity and Health
Table 6-2.
Continued
Study
Design
Theoretical approach
Population
Marcus, Banspach, et al.
6 week
Stages of change
610 sample of community
(1992) (Pawtucket Heart
pretest-posttest
residents, mean age = 42
Health Program: Imagine
uncontrolled
Action)
Worksites
Blair et al. (1986)
2 year
None
4,300 Johnson & Johnson
(Live for Life)
quasi-experimental
employees
Fries et al. (1993)
24 month
None
4,712 Bank of America
experimental
retirees
Heirich et al. (1993)
3 year
None specified
1,300 automobile plant
experimental
workers
Communication
Osler and Jespersen
2 year
Social learning theory,
Rural communities in
(1993)
quasi-experimental
communications
Denmark (n = 8,000 [I])
(diffusion of innovations);
community organization
Owen et al. (1995)
2 year
Social learning theory,
2 national physical activity
pretest-posttest
social marketing theory
campaigns in Australia
Brownell, Stunkard,
Study 1: 8 week
None specified
21,091 general public
Albaum (1980)
quasi-experimental
observations at a mall,
train station, bus terminal
Study 2: 4 month
None specified
24,603 general public
quasi-experimental
observations at a train
station
Blamey, Mutrie,
16 week
None
22,275 subway users
Aitchison (1995)
quasi-experimental
observations
I = intervention; C = control or comparison group.
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223
Understanding and Promoting Physical Activity
Intervention
Findings and comments
Written materials, resource manual, weekly fun
Participants more active after intervention with movement
walks, and activity nights
toward action and low relapse to earlier stage; suggests
stage-based community intervention can result in movement
toward action; study uncontrolled
I: Screening; lifestyle seminar; exercise programs; ; 20% of women and 30% of men began vigorous exercise
newsletters; contests; health communications;
of 2 years
no smoking policies
C: Screening only
I-1:Health risk appraisal; feedback letter;
No difference in physical activity year 1; I-1 greater
behavioral management materials; personalized d physical activity in year 2 over I-2
health promotion program
I-2:Health risk appraisal; no feedback; full
program in year 2
C: No intervention
I-1:Fitness facility
Percent exercising 3 times per week: I-1 = 30%, ,
I-2:Outreach and counseling to high risk employees s I-2 = 44%, I-3 = 45%, C = 37%
I-3:Outreach and counseling to all employees
C: Health education events
I: Heart Week with assessments, health
No difference in self-reported physical activity, but
education, weekly community exercise, TV,
intervention community expressed more interest in becoming
radio, newspaper community messages
active; low response rate to surveys (59%); became mainly
C: Not specified
a media campaign with little community involvement
I: Messages to promote walking and readiness to
1st campaign—increase in percent who walked for exercise
become active; modeling activity; radio and TV
(70% to 74%), greatest impact on 50+ age group (twofold
PSAs; T-shirts; special scripting of soap operas
increase in reported walking—not significant)
2nd campaign—small declines in reported walking and
in intentions to be more active
I: Sign reading “Your heart needs exercise—
Number of people using the stairs increased from 5%
here’s your chance”
to 14% when sign was up.  Use declined to 7% when
sign was removed
I: Sign reading “Your heart needs exercise—
Number of people using the stairs increased from 12% to
here’s your chance”
18%; effect remained for 1 month after sign was removed
I: Sign reading “Stay Healthy, Save Time,
Baseline stair use increased to 15–17% when sign
Use the Stairs”
was up; persisted at 12 weeks after sign removal;
larger increase among men
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224
Physical Activity and Health
Table 6-2.
Continued
Study
Design
Theoretical approach
Population
Special populations: ethnic minorities
Heath et al. (1991)
2 year
None specified
86 Native Americans
quasi-experimental
with diabetes
Lewis et al. (1993)
3 year
Constituency-based
African American
quasi-experimental
model
residents of 6 public
housing units
Nader et al. (1989)
3 month
Social learning theory
623 Mexican and Anglo-
(San Diego Family
experimental
American families with
Health Project)
9 month
5th grade children
maintenance
Baranowski et al.
14 weeks
None specified
94 black families (63
(1990)
adults, 64 children)
Special populations: persons at risk for chronic disease
Perri et al. (1988)
18 month
Behavioral management
123 overweight adults
experimental
Jeffery (1995)
7 year
None mentioned
280 community
uncontrolled
members trying
to lose weight
King et al. (1989)
2 year
None mentioned
96 men trying to
experimental
maintain weight
loss
Special Populations:  older adults
Mayer et al. (1994)
2 year
Social learning theory
1,800 Medicare
experimental
beneficiaries in HMO,
mostly white, high SES
I = intervention; C = control or comparison group.
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225
Understanding and Promoting Physical Activity
Intervention
Findings and comments
I: Exercise class
Participants in the exercise program lost 4 kg of weight
C: Nonparticipants
on average, compared with 0.9 kg among nonparticipants;
improvements occurred in fasting blood glucose
levels and medication requirements
I-1:Basic exercise program
Communities that were better organized and had more
I-2:Basic exercise program; social; goal setting;
committed leaders had better program attendance and
attention; information; barrier reduction
higher physical activity levels
I: Family newsletter; telephone; mail; personal
No difference in physical activity at 1 year
contact; feedback; family behavior manage-
ment; physical activity; nutrition education
C: Periodic evaluation
I: Individual counseling, small group education,
No difference in energy expenditure;  low
aerobic activity, incentives (babysitting,
participation (20%)
transportation), telephone prompts, assessment
C: Assessment only
I-1:Behavior therapy
Difference adherence in high exercise groups at 6 months;
I-2:Behavior therapy, maintenance
no differences at 12 and 18 months; high attrition (24%)
I-3:Behavior therapy, maintenance, social influence
I-4:Behavior therapy, maintenance, exercise
I-5:Behavior therapy, maintenance, exercise, social
influence
I-1:Diet management
I-2 resulted in greater weight loss at end, but no
I-2:Weight management, including exercise
differences were observed at 1 year
I-3:Physical activity
I: Monthly mailings, advice and tips for coping,
Men who exercised and received the intervention regained
staff telephone calls
less weight in year 2 than exercisers who did not get
C: No intervention
the intervention or dieters who were exposed to the
intervention
I: Health risk appraisal, feedback, health
No change in physical activity (3+ times a week) at 1 year,
education sessions, medical tests, immuniza-
but 21% vs.14% moved from sedentary to active
tions, goal setting, self-monitoring
(no statistical test reported); attrition 16% in experimental
C: Not specified
group at 1 year
226
Physical Activity and Health
self-monitoring group had significantly better
adherence over 12 weeks than those in the self-
monitoring plus attention or control groups; how-
ever, adherence over the last 6 weeks of the study was
significantly better in the self-monitoring plus atten-
tion group. Actual differences were not large, amount-
ing to 4 to 5 days of gym attendance over 3 weeks,
compared with about 3 days among controls. In all
three groups, adherence dropped off most sharply
during the first 6 weeks of the study.
Classes, health clubs, and fitness centers are
resources to promote physical activity, and numer-
ous studies have been undertaken to improve atten-
dance (Table 6-2). However, many people prefer to
exercise on their own. Several studies have used
behavioral management techniques to encourage
people to do so on their own (Table 6-2). In some
studies, training in behavioral management tech-
niques has occurred in a group setting before the
participants began exercising on their own; in oth-
ers, information has been provided by mail. Results
have been equivocal. King, Haskell, and colleagues
(1995) assigned 50- through 65-year-old partici-
pants to one of three conditions: a vigorous, group-
based program (three 60-minute sessions); a
vigorous, home-based program (three 60-minute
sessions); and a moderate, home-based program
(five 30-minute sessions). At 1 year, adherence was
significantly greater in both home-based programs
than in the group-based program. At 2 years, how-
ever, the vigorous, home-based program had higher
adherence than the other two programs. Research-
ers hypothesize that it was more difficult for the
moderate group to schedule 5 days of weekly physi-
cal activity than for the vigorous group to schedule
3 days. Another study encouraged self-monitoring
and social support (walking with a partner) and
also tested a schedule of calling participants to
prompt them to walk. Frequent calls (once a week)
resulted in three times the number of reported
episodes of activity than resulted from calling every
3 weeks (Lombard, Lombard, Winett 1995). Cardi-
nal and Sachs (1995) randomly assigned 133 women
to receive one of the three packets of information
promoting physical activity: self-instructional pack-
ages that were based on stage of change and that
provided tailored feedback; a packet containing a
standard exercise prescription; and a packet pro-
viding minimal information about health status and
exercise status. No significant differences were
observed among the three groups at baseline, 1
month, or 7 months.
The advent of interactive expert-system com-
puter technologies has allowed for increased indi-
vidualization of mailed feedback and other types of
printed materials for health promotion (Skinner,
Strecher, Hospers 1994). Whether these technolo-
gies can be shown to be effective in promoting
physical activity at low cost is yet to be determined.
In summary, behavioral management approaches
have been employed with mixed results. Where an
effect has been demonstrated, it has often been small.
Evidence of the effectiveness of techniques like self-
monitoring, frequent follow-up telephone calls, and
incentives appear to be generally positive over the
short run, but not over longer intervals. Evidence on
the relative effectiveness of interventions on adher-
ence to moderate or vigorous activity is limited and
unclear. Because of the small number of studies, the
variety of outcome measures employed, and the di-
versity of settings examined, it is not clear under what
circumstances behavioral management approaches
work best.
In a number of studies, methodological issues,
such as high attrition rates, short follow-up, small
sample sizes, lack of control or comparison groups,
incomplete reporting of data, or lack of clarity about
how theoretical constructs were operationalized,
also make it difficult to determine the effectiveness
of behavioral management approaches or to general-
ize results to other settings or population groups.
Stages of change theory suggests that people move
back and forth across stages before they become able
to sustain a behavior such as physical activity. The
relatively short time frame of many studies and the
use of outcome measures that are not sensitive to
stages of change may have limited the ability to
determine if and to what extent possessing behav-
ioral management skills is useful in the maintenance
of regular physical activity.
Interventions in Health Care Settings
Health care settings offer an opportunity to indi-
vidually counsel adults and young people about
physical activity as well as other healthful behaviors,
such as dietary practices (U.S. Preventive Services
Task Force 1996). Approximately 80 percent of the
227
Understanding and Promoting Physical Activity
U.S. population see a physician during a 1-year
period (National Center for Health Statistics 1991),
but the extent to which physicians counsel their
patients to be physically active is unclear. One survey
of physicians found 92 percent reporting that they or
someone in their practice counseled patients about
exercise (Mullen and Tabak 1989), but in a more
recent study, only 49 percent of primary care physi-
cians stated they believed that regular daily physical
activity was very important for the average patient
(Wechsler et al. 1996). Counseling is likely to be
brief, often less than 2 minutes (Wells et al. 1986),
and ineffective counseling approaches are often
employed (Orleans et al. 1985). Physicians may be
less likely to counsel patients about health habits if
their own health habits are poor (Wells et al. 1984).
Only three studies attempting to improve the
physical activity counseling skills of primary care
physicians have been reported in the literature; the
results suggest small but generally positive effects on
patients, with from 7 to 10 percent of sedentary
persons starting to be physically active (Table 6-2).
One feasibility trial of multiple risk factor reduction—
the Industrywide Network for Social, Urban, and
Rural Efforts (INSURE) Project—indicates that con-
tinuing medical education seminars, combined with
reimbursement for prevention counseling and re-
minders to providers, can increase the percentage of
these physicians’ patients who subsequently start exer-
cising (Logsdon, Lazaro, Meir 1989). The Physician-
based Assessment and Counseling for Exercise (PACE)
program incorporated social cognitive theory and the
transtheoretical model to individualize brief (2–5
minutes) counseling messages for patients. Com-
pared with patients who did not receive the program
counseling, those who did had significantly greater
improvements at 4–6 weeks in their reported stage of
physical activity readiness, their reported amount of
walking for exercise, and their scores from an activity
monitor (Calfas et al. in press).
The Canadian Task Force on the Periodic Health
Examination (1994) cited insufficient evidence as
the reason for not making a recommendation regard-
ing physical activity counseling. However, several
other professional organizations have recently rec-
ommended routine physical activity counseling. The
American Heart Association (Fletcher et al. 1992),
the American Academy of Pediatrics (1994), the
American Medical Association (1994), the President’s
Council on Physical Fitness and Sports (1992), and
the U.S. Preventive Services Task Force (1989, 1996)
all recommend including physical activity counsel-
ing as part of routine clinical preventive services for
both adults and young people.
In summary, many providers do not believe that
physical activity is an important topic to discuss with
their patients, and many lack effective counseling
skills. The studies that have attempted to increase
provider counseling for physical activity demonstrate
that providers can be effective in increasing physical
activity among their patients. It is not known what
alternative approaches to provider counseling can be
used effectively in health care settings, although the
work of Mayer and colleagues (1994) suggests that
well-trained counselors conducting health education
classes with patients may help older adults make
changes in their stage of physical activity.
Community Approaches
Communitywide prevention programs have evolved
from the concept that a population, rather than an
individual, approach is required to achieve primary
prevention of disease through risk factor reduction
(Luepker et al. 1994). Behaviors and lifestyle choices
that contribute to an individual’s risk profile are
influenced by personal, cultural, and environmental
factors (Bandura 1977b). Much of the current knowl-
edge regarding community-based prevention strate-
gies has been gained over the past 20 years from three
U.S. research field trials for community-based health
promotion—including physical activity promotion—
to reduce cardiovascular disease (Table 6-2).
These three trials, which were funded by the
National Heart, Lung, and Blood Institute during the
1980s, were the Minnesota Heart Health Program
(MHHP) (Luepker et al. 1994), the Pawtucket Heart
Health Program (PHHP) (Carleton et al. 1995), and
the Stanford Five-City Project (SFCP) (Farquhar et al.
1990). The MHHP advocated regular physical activity
as part of its broad effort to reduce risk for CHD in
whole communities in the upper Midwest (Crow et al.
1986; Mittelmark et al. 1986). Three intervention
communities received a 5- to 6-year program designed
to reduce smoking, serum cholesterol, and blood
pressure and to increase physical activity; three other
communities served as comparison sites. Mass media
were used to educate the public about the relationship
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