Mini-review
Meta-analysis of patient education interventions to increase physical activity among chronically ill adults

https://doi.org/10.1016/j.pec.2007.10.004Get rights and content

Abstract

Objective

This meta-analysis integrates primary research testing the effect of patient education to increase physical activity (PA) on behavior outcomes among adults with diverse chronic illnesses.

Methods

Extensive literature searching strategies located published and unpublished intervention studies that measured PA behavior outcomes. Primary study results were coded. Fixed- and random-effects meta-analytic procedures included moderator analyses.

Results

Data were synthesized across 22,527 subjects from 213 samples in 163 reports. The overall mean weighted effect size for two-group comparisons was 0.45 (higher mean for treatment than control). This effect size is consistent with a difference of 48 min of PA per week or 945 steps per day. Preliminary moderator analyses suggest interventions were most effective when they targeted only PA behavior, used behavioral strategies (versus cognitive strategies), and encouraged PA self-monitoring. Differences among chronic illnesses were documented. Individual strategies unrelated to PA outcomes included supervised exercise sessions, exercise prescription, fitness testing, goal setting, contracting, problem solving, barriers management, and stimulus/cues. PA outcomes were unrelated to gender, age, ethnicity, or socioeconomic distribution among samples.

Conclusion

These findings suggest that some patient education interventions to increase PA are effective, despite considerable heterogeneity in the magnitude of intervention effect.

Practice implications

Moderator analyses are preliminary and provide suggestive evidence for further testing of interventions to inform practice.

Introduction

Health care providers routinely recommend physical activity (PA) to many adults with chronic illnesses. Despite widespread recognition of potential health and well-being benefits of PA, most adults with chronic illnesses remain sedentary. Numerous primary studies have tested diverse patient education interventions to increase PA, and many authors have reviewed these investigations. Most reviews, including meta-analyses, have focused on benefits of PA. The many narrative reviews focused on PA behavior outcomes have examined limited domains of this broad literature, such as computer-tailored interventions [1]; primary care-based interventions [2], [3], [4], [5]; environmental interventions [6], [7]; mass media-delivered interventions [8]; interventions designed to increase ‘lifestyle’ PA (versus episodic exercise) [9], [10]; interventions targeting older adults [11], [12]; studies addressing subpopulations such as African-Americans [13], [14], [15], [16], [17], [18], [19]; and intervention studies based on particular theoretical models [20]. Narrative reviews discussing PA behavior outcomes often address very few of the available studies [21], [22], [23], [24]. Narrative reviews often rely heavily on previous reviews [19], perhaps because it is difficult to conduct a narrative summary across many studies. Narrative reviews generally do not offer conclusions about the efficacy of interventions because evidence that appears contradictory is difficult to synthesize without quantitative integration [25], [26]. This quantitative synthesis meets the current pressing need to integrate this large body of research to inform future research and facilitate behavior change theory development.

Few meta-analyses have examined PA outcomes following patient education interventions. Hillsdon et al. [27] synthesized across only 11 primary studies with healthy adults that reported PA outcomes. Conn et al. [11] synthesized intervention studies conducted with healthy and chronically ill aging adults. Ashworth et al. [28] further limited their meta-analysis of studies conducted with older adults to comparisons between home-based versus center-based interventions. Over a decade ago, Dishman and Buckworth [29] conducted the broadest meta-analysis across 127 studies of healthy and chronically ill adults and children. Fewer than 20% of the studies included in that study focused on persons with chronic illness. The authors reported that intervention effects sizes (ESs) were smaller among studies with chronically ill subjects than in studies with healthy subjects. In contrast, Conn et al. [11] reported that among studies of older adults, interventions targeting samples with specific chronic illnesses reported larger ESs than studies with diverse older adults. No comprehensive meta-analyses have been reported that address PA behavior following patient education interventions among adults with diverse chronic illnesses. This meta-analysis was designed to integrate primary study findings from interventions designed to increase PA behavior among adults with chronic illnesses.

This synthesis addressed the following questions: (1) What are the overall effects of interventions to increase PA on PA behavior after interventions? (2) Do interventions’ effects on PA behavior vary depending on characteristics of interventions, sample, or methodology? (3) For controlled trials, do control groups’ post-test outcome measures different significantly from pre-test values?

Section snippets

Methods

We used standard quantitative review methods to identify and retrieve potential primary studies, determine study eligibility, reliably code data, synthesize results across primary studies, and interpret findings [30], [31], [32], [33], [34], [35].

Results

A total of 213 samples including 22,557 subjects from 163 reports were eligible for the meta-analysis (numbers of subjects should be considered close approximations, given vagaries of primary study reporting) [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69], [70], [71], [72], [73], [74], [75], [76], [77], [78], [79], [80], [81], [82], [83], [84], [85], [86], [87], [88], [89], [90], [91], [92], [93], [94], [95], [96], [97], [98], [99], [100], [101], [102],

Discussion

This is the first meta-analysis to examine PA behavior following patient education interventions designed to increase PA among diverse chronically ill populations. Our extensive search strategies successfully located a sizable and diverse literature. A moderate overall ES was calculated. The overall ES is between the values previously reported for older adults and for predominantly healthy adults [11], [29]. In subgroup analyses, Dishman and Buckworth reported considerably smaller ESs for the

Acknowledgement

Financial support provided by a grant from the National Institutes of Health (R01NR07870) to Vicki Conn, principal investigator.

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