Primary Care Assessment and Interventions to Improve Physical Activity Among Insufficiently Active

188 Pages·2015·1.74 MB·English

by  Thomas A. Sanchez

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Doctoral Dissertations Graduate Research and Creative Practice
12-2014
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Thomas A. Sanchez
Grand Valley State University
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Insufficiently Active Adults Ages 18 Through 64 Years Old" (2014). Doctoral Dissertations. 24.
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PRIMARY CARE ASSESSMENT AND INTERVENTIONS TO IMPROVE
PHYSICAL ACTIVITY AMONG INSUFFICIENTLY ACTIVE ADULTS AGES 18
THROUGH 64 YEARS OLD

Thomas Alden Sanchez

A Dissertation Submitted to the Graduate Faculty of

GRAND VALLEY STATE UNIVERSITY

In

Partial Fulfillment of the Requirements

For the Degree of

DOCTOR OF NURSING PRACTICE

Kirkhof College of Nursing

December 2014
Dedication

To my wife Michelle, who tolerated several years of evening and weekend work to
complete this dissertation and the degree that goes with it. She received a number of
crunch-time requests for writing consultation and gave her fresh and enlightening
perspective as a consumer and reader from outside the healthcare professions.
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Acknowledgement

Dr. Cynthia Coviak patiently offered advice and hints about strategies and what to
think about next over the last several years. She pointed out internal and external
obstacles along the way and herded this cat to completion, which was no small task.
Adam Popour, a Grand Valley State University (GVSU) Family Health Center (FHC)
employee and IT student, created a software tool to calculate the MET-minutes per week
and the physical activity category from the IPAQ results. He also helped create places to
enter the results and links to pull PA assessment data into progress notes. He tirelessly
went after technical glitches until everything worked. Eventually this work was set aside
because the health center switched EHRs mid-project. Rhonda Pardue then helped me
create a new IPAQ calculator in Excel by writing the complex result formula that
captures all the dependent clauses of the instructions.
The current and former staff of the GVSU FHC graciously permitted me to learn
and carry out my project in their working environment. MaryJo, Anne, Beth, Kathy,
Kim, Ann, and Larry collaborated on the process change, helped revise working
documents and showed a desire to see best practices enacted. Sarah Portenga and Nicole
Hansen of the YMCA Greater Grand Rapids helped develop the processes for linking
their established community programs to primary care sites. Julie Sielewa of the YMCA
Greater Grand Rapids, let this DNP student into the administrative offices under her
direction to find a place to make community-level connections that may become a game-
changer in healthcare. The Statistical Consulting Center of GVSU headed by Dr. Sango
Otieno, along with Melissa and a cadre of other students, contributed helpful ideas that
were both amusing and educational.
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Abstract

A number of chronic and debilitating conditions such as cardiovascular disease,
stroke, hypertension, anxiety, depression, pain, osteoporosis, and falls are known to be
delayed, improved, or prevented by increasing physical activity (PA) levels. The
numbers of those affected form a substantial portion of the US population. As of 2011,
for example, 26 million adults in the U.S. were diagnosed with diabetes mellitus (DM)
alone. Another 79 million people had elevated blood glucose measurements putting them
at risk for DM. Despite knowledge of the connection with chronic disease, PA levels are
not consistently and quantitatively assessed during primary care office visits. Healthcare
providers often believe lifestyle change intervention with sedentary adults is futile and
encounter barriers to regular PA for many low-income, inner-city clients.
Barriers are potentially reduced through partnership with the YMCA (Y1), which
cooperates with local churches and community organizations to open sites that offer
nutrition and exercise classes at no cost to participants. Healthcare providers at the
Grand Valley State University Family Health Center (FHC) did not previously refer
sedentary clients to the Y. Referral to the Y became an innovative part of an evidence-
based intervention set.
Quality enhancements were put in place at the FHC, guided by a logic model to
improve PA assessment and intervention. A policy was written that specifies the process
to be used to evaluate and document clients' PA levels and application of interventions
for those clients who were assessed and found to have suboptimal habitual PA levels.
Assessment uses the International Physical Activity Questionnaire self-report, short-form

1 The YMCA was the historic acronym for the Young Men‟s Christian Association, but
its name is now formally the YMCA. The current official acronym is simply the Y.
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because it yields numeric and categorical results that allow tracking of progress and
determination of the need for PA intervention. A low to moderate PA level result now
triggers implementation of an evidence-based intervention set consisting of counseling,
printed educational materials, and an offer of referral to Y community outreach programs.
The electronic health record-embedded educational material was written to facilitate
teaching and client self-review.

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Table of Contents

List of Tables................................................................................................................. 10

List of Figures ............................................................................................................... 11

List of Appendices ......................................................................................................... 12

Chapter

1 INTRODUCTION......................................................................................... 13
The Global Scope and Effects of Sedentary Lifestyles .............................. 16
Exercise Guidelines Target Insufficiently Active Adults ........................... 17
Effectiveness of PA for Reducing Risk of Various Diseases ..................... 21
Contributions of the Social and Built Environment and Fees..................... 22
Current Status of Primary Care Promotion of PA ...................................... 23
Clinical Staff Survey of Usual PA Practice .......................................... 26
Summary of the Project Focus .................................................................. 28

2 LITERATURE REVIEW .............................................................................. 30
Current Knowledge of the Associations Between Disease and PA ............ 30
Cardiovascular Disease, Diabetes, Overweight and Obesity ................. 31
Depression and mental health, dysmenorrhea and fibromyalgia ........... 32
Muskuloskeletal health ........................................................................ 34
Cancer ................................................................................................. 36
Interventions to Promote PA Applicable to PC Settings ............................ 38
PA Counsel or Advice ......................................................................... 39
Telephone Follow-up ........................................................................... 54
Printed, Internet, and Media-Based PA Education................................ 57
Community Agency Referral ............................................................... 59
Composite PA Intervention Sets with Other Characteristics ................. 61
Attention to Facilitators and Barriers ........................................................ 66
Summary Intervention Strategy for this Project......................................... 67

3 CONCEPTUAL FRAMEWORK .................................................................. 71
Conceptual Frameworks for PA Interventions........................................... 73
Social cognitive theory and self-efficacy .............................................. 73
The health promotion model ................................................................ 76
The transtheoretical model ................................................................... 78
Summary of the conceptual framework for the intervention ................. 80
Implementation of PA Interventions Using a Logic Model ....................... 81
Logic Model inputs .............................................................................. 83
Logic Model outputs ............................................................................ 84
Logic Model outcomes, impact and goals ............................................ 85
Summary .................................................................................................. 87

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4 METHODS ................................................................................................... 89
Location ................................................................................................... 90
Target Client Population, Inclusion, Exclusion and Risks ......................... 90
Key Stakeholders...................................................................................... 93
Barriers overcome ............................................................................... 96
Facilitators Enlisted in the Project ............................................................ 98
Measurement ............................................................................................ 99
PA level measurement for this project.................................................. 99
IPAQ-short form reliability and validity ........................................ 102
Roll-out of the PA Intervention Set ......................................................... 104
Institutional review board .................................................................. 106
Staff training in use of the intervention set ......................................... 106
Project Summary ................................................................................... 107

5 PROJECT OUTCOMES ............................................................................ 110
PA Assessment Tools ............................................................................. 110
The IPAQ-short form ......................................................................... 110
The IPAQ Calculator ......................................................................... 111
The IPAQ fit, workflow, EHR changeover......................................... 112
FHC and Y Collaboration ....................................................................... 115
Intervention Protocol .............................................................................. 118
PA counsel ........................................................................................ 119
Educational flyer ............................................................................... 119
Other Embedded Documentation ....................................................... 120
PA Readiness Assessment ...................................................................... 120
FHC PA Policy Document ...................................................................... 121
Summary ................................................................................................ 122

6 DISCUSSION ............................................................................................. 123
Impact and Lessons Learned ................................................................... 123
Impact on the Triple Aim ................................................................... 124
Population health .......................................................................... 124
Cost reduction ............................................................................... 125
Experience of care ........................................................................ 126
A Logic Model as an implementation tool ......................................... 126
The health promotion (HPM) and transtheoretical models (TTM) ...... 127
Policy Implications ............................................................................ 128
Sustainability ..................................................................................... 130
Limitations ............................................................................................. 132
Recommendations .................................................................................. 134
Expansion of the emphasis on PA as a vital sign ................................ 134
Referral ............................................................................................. 135
Use of rapidly advancing technology ................................................. 135
Partnership with community resources to support PA ........................ 137
Community site attendance data ........................................................ 137
Doctor of Nursing Practice (DNP) role implementation .......................... 139
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Clinician ............................................................................................ 139
Leader ............................................................................................... 140
Advocate ........................................................................................... 141
Scholar .............................................................................................. 142
Innovator ........................................................................................... 143
Educator ............................................................................................ 144
Summary ............................................................................................... 145

APPENDICES ............................................................................................................. 148

REFERENCES ............................................................................................................ 169

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List of Tables

TABLE

1 HP 2020 Physical Activity Objectives that this Project Addresses ............ 20

2 IPAQ Data Collection February through May, 2014 .............................. 113

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