Country | England | Australia | The Netherlands |
Design | Randomized controlled trial | Cluster randomized controlled trial | Cluster randomized controlled trial |
Setting or practitioners | 4 settings: deprived inner city, rural small town, market town, cathedral city | 75 GPs | 29 practices |
Population | Patients = 18 y with hypertension, hyperlipidemia, BMI > 25, or diabetes | Patients 40-70 y with (n = 329) and without (n = 438) hypertension | Patients 18-70 y with hypertension, hypercholesterolemia, or type 2 diabetes |
Recruitment | Invitation letters | During routine visits | Invitation letters and leaflets |
Intervention | 8 groups: no intervention, a single intervention, or any combination of the 3 interventions. Counseling was based on the theory of planned behaviour. The 3 interventions were as follows:
-
a doctor’s prescription for brisk exercise not requiring a leisure facility (eg, walking) 30 min/d, 5 d/wk; -
counseling by practice nurses based on a psychological theory to modify intentions and perceived control of behaviour and using behavioural implementation techniques; and -
use of the Health Education Authority booklet Getting Active, Feeling Fit
| 4 groups: health promotion intervention, health promotion control, risk factor (hypertension) intervention, risk factor (hypertension) control. The strategy was similar in the 2 intervention groups; the focus of the advice was different.
Patients in the health promotion group received material and advice encouraging them to be more active. Patients in the risk factor intervention group received material and advice encouraging them to be more active and to manage their hypertension better. The advice and prescription for physical activity were supplemented with self-help booklets.
Distribution of booklets was guided by stage of motivation and readiness for physical activity and behavioural support strategies | All patients received advice on becoming more active from GPs or NPs during 10-min consultations at baseline. The intervention comprised 2 visits with providers and 2 booster telephone calls. At the first visit, patients filled out stage-assessment forms and forms for 1 of 3 counseling protocols. Protocols contained stage-specific information and questions that patients answered before the next visit. A physical activity counselor called patients 2 wk after the initial visit to provide encouragement and resolve problems. Follow-up consultations took place 4 wk after initial visits; final telephone calls followed 8 wk later. In the control group, providers briefly questioned patients about current levels of activity and, when appropriate, encouraged them to become more active |
Primary outcome | Level of physical activity assessed at 1 mo using Godin’s questionnaire | Level of physical activity assessed at 2 and 6 mo using the short form of the International Physical Activity Questionnaire | Level of physical activity assessed at 8 wk and 6 and 12 mo by the Short Questionnaire to Assess Health-enhancing Physical Activity |
Analysis | Nonparametric test for trend | Bivariate cluster-adjusted analyses to compare the differences between groups with the generalized estimating equation accounting for the correlated structure within practices | Linear regression analyses, multilevel model (timing of follow-up, the individual, and the general practice) adjusted for confounders. Follow-up measurements were defined as dependant variables; baseline values of dependant variables were included as covariates. Regression coefficients for groupallocation variables reflected average differences in outcome variables over time. Multilevel modeling (individual and general practice) was also used to assess changes within the study population from baseline to 1-y follow-up |
Results | Follow-up response rate was 82%. There was a trend from the least intensive (control with or without booklet) to the most intensive (prescription and counseling with or without booklet) interventions. There was significant increase in physical activity from baseline (Godin’s score 14.4, 95% CI 7.8-21; test for trend, P = .02) only with the most intensive intervention. Combining exercise prescription and counseling explicitly based on psychological theory likely led to important increases in physical activity | Follow-up response rates were 92% and 84% at the 2- and 6-mo assessments. Neither intervention strategy resulted in significant changes in self-reported physical activity regardless of whether the advice was tailored to hypertension management or consisted of general health promotion information | Follow-up response rates were 94%, 89%, and 86% at the 8-wk and 6- and 12-mo assessments. No significant effect of the intervention over time was observed on level of physical activity, but the study population as a whole exhibited a significant increase in physical activity at 1-year follow up (mean increase 61.6 min, 95% CI 7.5-115.6 min) |