Participation of people living with disabilities in physical activity: a global perspective.

Approximately 1·5 billion people worldwide live with a physical, mental, sensory, or intellectual disability, about 80% of which are in low-income and middle-income countries. This Series paper provides a global overview of the prevalence, benefits, and promotion policies for physical activity for people living with disabilities (PLWD). PLWD are 16-62% less likely to meet physical activity guidelines and are at higher risk of serious health problems related to inactivity than people without disabilities. Meta-analyses have shown that physical activity has beneficial effects on cardiovascular fitness (average standardised mean difference [SMD] 0·69 [95% CI 0·31-1·01]), musculoskeletal fitness (0·59 [0·31-0·87]), cardiometabolic risk factors (0·39 [0·04-0·75]), and brain and mental health outcomes (0·47 [0·21-0·73]). These meta-analyses also show that health benefits can be achieved even with less than 150 min of physical activity per week, and suggest that some physical activity is better than none. Meta-analyses of interventions to increase physical activity for PLWD have reported effect sizes ranging from SMD 0·29 (95% CI 0·17-0·41, k=10) to 1·00 (0·46-1·53, k=10). There is increasing awareness among policy makers of the needs of PLWD for full participation in physical activity. Physical activity action plans worldwide must be adequately resourced, monitored, and enforced to truly advance the fundamental rights of PLWD to fully participate in physical activity.

A Pragmatic Application of the RE-AIM Framework for Evaluating the Implementation of Physical Activity as a Standard of Care in Health Systems.

INTRODUCTION: Exercise is Medicine (EIM) is an initiative that seeks to integrate physical activity assessment, prescription, and patient referral as a standard in patient care. Methods to assess this integration have lagged behind its implementation. PURPOSE AND OBJECTIVES: The purpose of this work is to provide a pragmatic framework to guide health care systems in assessing the implementation and impact of EIM. EVALUATION METHODS: A working group of experts from health care, public health, and implementation science convened to develop an evaluation model based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. The working group aimed to provide pragmatic guidance on operationalizing EIM across the different RE-AIM dimensions based on data typically available in health care settings. RESULTS: The Reach of EIM can be determined by the number and proportion of patients that were screened for physical inactivity, received brief counseling and/or a physical activity prescription, and were referred to physical activity resources. Effectiveness can be assessed through self-reported changes in physical activity, cardiometabolic biometric factors, incidence/burden of chronic disease, as well as health care utilization and costs. Adoption includes assessing the number and representativeness of health care settings that adopt any component of EIM, and Implementation involves assessing the extent to which health care teams implement EIM in their clinic. Finally, Maintenance involves assessing the long-term effectiveness (patient level) and sustained implementation (clinic level) of EIM in a given health care setting. IMPLICATIONS FOR PUBLIC HEALTH: The availability of a standardized, pragmatic, evaluation framework is critical in determining the impact of implementing EIM as a standard of care across health care systems.

Progress in physical activity over the Olympic quadrennium.

On the eve of the 2012 summer Olympic Games, the first Lancet Series on physical activity established that physical inactivity was a global pandemic, and global public health action was urgently needed. The present paper summarises progress on the topics covered in the first Series. In the past 4 years, more countries have been monitoring the prevalence of physical inactivity, although evidence of any improvements in prevalence is still scarce. According to emerging evidence on brain health, physical inactivity accounts for about 3·8% of cases of dementia worldwide. An increase in research on the correlates of physical activity in low-income and middle-income countries (LMICs) is providing a better evidence base for development of context-relevant interventions. A finding specific to LMICs was that physical inactivity was higher in urban (vs rural) residents, which is a cause for concern because of the global trends toward urbanisation. A small but increasing number of intervention studies from LMICs provide initial evidence that community-based interventions can be effective. Although about 80% of countries reported having national physical activity policies or plans, such policies were operational in only about 56% of countries. There are important barriers to policy implementation that must be overcome before progress in increasing physical activity can be expected. Despite signs of progress, efforts to improve physical activity surveillance, research, capacity for intervention, and policy implementation are needed, especially among LMICs.

Hospital Discharge Disposition of Stroke Patients in Tennessee.

OBJECTIVES: Early determination of hospital discharge disposition status at an acute admission is extremely important for stroke management and the eventual outcomes of patients with stroke. We investigated the hospital discharge disposition of patients with stroke residing in Tennessee and developed a predictive tool for clinical adoption. Our investigational aims were to evaluate the association of selected patient characteristics with hospital discharge disposition status and predict such status at the time of an acute stroke admission. METHODS: We analyzed 127,581 records of patients with stroke hospitalized between 2010 and 2014. Logistic regression was used to generate odds ratios with 95% confidence intervals to examine the factor outcome association. An easy-to-use clinical predictive tool was built by using integer-based risk scores derived from coefficients of multivariable logistic regression. RESULTS: Among the 127,581 records of patients with stroke, 86,114 (67.5%) indicated home discharge and 41,467 (32.5%) corresponded to facility discharge. All considered patient characteristics had significant correlations with hospital discharge disposition status. Patients were at greater odds of being discharged to another facility if they were women; older; black; patients with a subarachnoid or intracerebral hemorrhage; those with the comorbidities of diabetes mellitus, heart disease, hypertension, chronic kidney disease, arrhythmia, or depression; those transferred from another hospital; or patients with Medicare as the primary payer. A predictive tool had a discriminatory capability with area under the curve estimates of 0.737 and 0.724 for derivation and validation cohorts, respectively. CONCLUSIONS: Our investigation revealed that the hospital discharge disposition pattern of patients with stroke in Tennessee was associated with the key patient characteristics of selected demographics, clinical indicators, and insurance status. These analyses resulted in the development of an easy-to-use predictive tool for early determination of hospital discharge disposition status.

Parks, Trails, and Greenways for Physical Activity: A Community Guide Systematic Economic Review.

INTRODUCTION: This systematic economic review examined the cost-benefit and cost-effectiveness of park, trail, and greenway infrastructure interventions to increase physical activity or infrastructure use. METHODS: The search period covered the date of inception of publications databases through February 2022. Inclusion was limited to studies that reported cost-benefit or cost-effectiveness outcomes and were based in the U.S. and other high-income countries. Analyses were conducted from March 2022 through December 2022. All monetary values reported are in 2021 U.S. dollars. RESULTS: The search yielded 1 study based in the U.S. and 7 based in other high-income countries, with 1 reporting cost-effectiveness and 7 reporting cost-benefit outcomes. The cost-effectiveness study based in the United Kingdom reported $23,254 per disability-adjusted life year averted. The median benefit-to-cost ratio was 3.1 (interquartile interval=2.9-3.9) on the basis of 7 studies. DISCUSSION: The evidence shows that economic benefits exceed the intervention cost of park, trail, and greenway infrastructure. Given large differences in the size of infrastructure, intervention costs and economic benefits varied substantially across studies. There was insufficient number of studies to determine the cost-effectiveness of these interventions.

Evidence-based intervention in physical activity: lessons from around the world.

Promotion of physical activity is a priority for health agencies. We searched for reviews of physical activity interventions, published between 2000 and 2011, and identified effective, promising, or emerging interventions from around the world. The informational approaches of community-wide and mass media campaigns, and short physical activity messages targeting key community sites are recommended. Behavioural and social approaches are effective, introducing social support for physical activity within communities and worksites, and school-based strategies that encompass physical education, classroom activities, after-school sports, and active transport. Recommended environmental and policy approaches include creation and improvement of access to places for physical activity with informational outreach activities, community-scale and street-scale urban design and land use, active transport policy and practices, and community-wide policies and planning. Thus, many approaches lead to acceptable increases in physical activity among people of various ages, and from different social groups, countries, and communities.

Status and Trends of Physical Activity Surveillance, Policy, and Research in 164 Countries: Findings From the Global Observatory for Physical Activity-GoPA! 2015 and 2020 Surveys.

BACKGROUND: Physical activity (PA) surveillance, policy, and research efforts need to be periodically appraised to gain insight into national and global capacities for PA promotion. The aim of this paper was to assess the status and trends in PA surveillance, policy, and research in 164 countries. METHODS: We used data from the Global Observatory for Physical Activity (GoPA!) 2015 and 2020 surveys. Comprehensive searches were performed for each country to determine the level of development of their PA surveillance, policy, and research, and the findings were verified by the GoPA! Country Contacts. Trends were analyzed based on the data available for both survey years. RESULTS: The global 5-year progress in all 3 indicators was modest, with most countries either improving or staying at the same level. PA surveillance, policy, and research improved or remained at a high level in 48.1%, 40.6%, and 42.1% of the countries, respectively. PA surveillance, policy, and research scores decreased or remained at a low level in 8.3%, 15.8%, and 28.6% of the countries, respectively. The highest capacity for PA promotion was found in Europe, the lowest in Africa and low- and lower-middle-income countries. Although a large percentage of the world's population benefit from at least some PA policy, surveillance, and research efforts in their countries, 49.6 million people are without PA surveillance, 629.4 million people are without PA policy, and 108.7 million live in countries without any PA research output. A total of 6.3 billion people or 88.2% of the world's population live in countries where PA promotion capacity should be significantly improved. CONCLUSION: Despite PA is essential for health, there are large inequalities between countries and world regions in their capacity to promote PA. Coordinated efforts are needed to reduce the inequalities and improve the global capacity for PA promotion.

Improving risk stratification in patients with chest pain: the Erlanger HEARTS3 score.

BACKGROUND: The HEART score uses elements from patient History, Electrocardiogram, Age, Risk Factors, and Troponin to obtain a risk score on a 0- to 10-point scale for predicting acute coronary syndromes (ACS). This investigation seeks to improve on the HEART score by proposing the HEARTS(3) score, which uses likelihood ratio analysis to give appropriate weight to the individual elements of the HEART score as well as incorporating 3 additional "S" variables: Sex, Serial 2-hour electrocardiogram, and Serial 2-hour delta troponin during the initial emergency department valuation. METHODS: This is a retrospective analysis of a prospectively acquired database consisting of 2148 consecutive patients with non-ST-segment elevation chest pain. Interval analysis of likelihood ratios was performed to determine appropriate weighting of the individual elements of the HEART(3) score. Primary outcomes were 30-day ACS and myocardial infarction. RESULTS: There were 315 patients with 30-day ACS and 1833 patients without ACS. Likelihood ratio analysis revealed significant discrepancies in weight of the 5 individual elements shared by the HEART and HEARTS(3) score. The HEARTS(3) score outperformed the HEART score as determined by comparison of areas under the receiver operating characteristic curve for myocardial infarction (0.958 vs 0.825; 95% confidence interval difference in areas, 0.105-0.161) and for 30-day ACS (0.901 vs 0.813; 95% confidence interval difference in areas, 0.064-0.110). CONCLUSION: The HEARTS(3) score reliably risk stratifies patients with chest pain for 30-day ACS. Prospective studies need to be performed to determine if implementation of this score as a decision support tool can guide treatment and disposition decisions in the management of patients with chest pain.

Physical Activity and Public Health among People with Disabilities: Research Gaps and Recommendations.

Physical activity has become an integral component of public health systems modeling the public health core functions of assessment, policy development, and assurance. However, people with disabilities have often not been included in public health efforts to assess, develop policies, or evaluate the impact of physical activity interventions to promote health and prevent disease among people with disabilities. Addressing the core function of assessment, current physical activity epidemiology, and surveillance among people with disabilities across the globe highlights the paucity of surveillance systems that include physical activity estimates among people with disabilities. The status of valid and reliable physical activity measures among people with condition-specific disabilities is explored, including self-report measures along with wearable devices, and deficiencies in measurement of physical activity. The core functions of policy development and assurance are described in the context of community-based intervention strategies to promote physical activity among people with disabilities. The identification of research gaps in health behavior change, policy, and environmental approaches to promoting physical activity among people with disabilities is explored, along with recommendations based on the principles of inclusive and engaged research partnerships between investigators and the members of the disability community.

Dissemination of effective physical activity interventions: are we applying the evidence?

BACKGROUND: Given sparse knowledge on dissemination, this study sought to explore key benefits, barriers and contextual factors that are perceived to be important to the adoption and implementation of the 'Community Guide's' evidence-based physical activity recommendations. DESIGN: We conducted case studies in two states where extensive adoption and implementation of the Guide's recommendations have occurred and in two states where widespread dissemination has lagged. Interviews (n = 76) were semi-structured and included both quantitative and qualitative methods. Participant perceptions from the following areas were examined: (i) priority of physical activity, (ii) awareness of and ability to define the term 'evidence-based approaches' and (iii) awareness, adoption, facilitators, benefits, challenges and barriers to Guide adoption. RESULTS: Key enabling factors among high capacity states included: funds and direction from the Centers for Disease Control and Prevention; leadership support; capable staff; and successful partnerships and collaborations. Restraining forces among low capacity states included: the Guide recommendations being too new; participants being too new to current job; lack of time and training on how to use the Guide recommendations; limited funds and other resources and lack of leadership. CONCLUSION: To be effective, we must gain an understanding of contextual factors when designing for dissemination.

Grow Healthy Together: Effects of Policy and Environmental Interventions on Physical Activity Among Urban Children and Youth.

BACKGROUND: There is a paucity of studies, especially among diverse populations, demonstrating the effects of policy and environmental interventions to increase regular physical activity. The Grow Healthy Together Chattanooga project provided the opportunity to assess the impact of physical activity policy and environmental interventions on the physical activity among predominately African American children living in the inner city. METHODS: Using the System for Observing Physical Activity and Recreation in Communities (SOPARC), the authors examined the physical activity of children along urban pedestrian/bike routes/trails and recreational park areas within the boundaries of the Grow Healthy Together Chattanooga communities. SOPARC data were collected at baseline (fall 2010/spring 2011) and repeated (spring 2014) in each community. RESULTS: The SOPARC assessments yielded a total of 692 child/youth observations in 2010 and 806 observations in 2014. Children/youth observed in 2014 were greater than 2 times the odds of engaging in moderate/vigorous physical activity compared with their 2010 counterparts (odds ratio = 2.75, 95% confidence interval, 1.43-5.32). CONCLUSIONS: The present findings support the hypothesis that policy and environmental interventions can contribute to increased physical activity levels among children/youth over ∼3-year period. These results provide evidence that improved access to "urban" pedestrian/bicycle routes/trails appears to translate into increased opportunities for physical activity among inner city children/youth.

Effects of an automatic discontinuation of antibiotics policy: A novel approach to antimicrobial stewardship.

PURPOSE: A novel automatic discontinuation policy implemented within an antimicrobial stewardship program (ASP) is described, and results of an evaluation of the policy's effects on antibiotic usage are reported. METHODS: A retrospective, before-and-after study was conducted at an 800-bed, tertiary care, academic teaching hospital to evaluate selected antibiotic usage outcomes in both intensive care unit (ICU) and non-ICU adult patients targeted for ASP interventions before and after implementation of an automatic discontinuation of antibiotics policy (ADAP) authorizing the ASP team to automatically halt antibiotic therapy in cases involving inappropriate duplicate antimicrobial coverage or excess duration of therapy. The primary outcome was total days of antibiotic therapy. Secondary outcomes included excess days of therapy and rates of 30-day readmission, Clostridioides difficile infection, and multidrug-resistant infection. RESULTS: There were no statistically significant differences in group demographics or clinical characteristics. The most common indication for antibiotics was hospital-acquired pneumonia, and the most common reason for ASP intervention was excess duration of therapy. The mean total number of antibiotic days per patient was reduced from 7.6 days in the pre-ADAP group to 6.6 days in the post-ADAP group (p < 0.05). The mean number of excess days of antibiotics was similarly reduced, from 2.3 days to 1.5 days, after implementation of the ADAP (p < 0.05). CONCLUSION: Adoption of an ADAP-a more active approach to ASP interventions-was effective in reducing overall antibiotic usage and improving the efficiency of the ASP.

Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association.

SUMMARY: In 1995 the American College of Sports Medicine and the Centers for Disease Control and Prevention published national guidelines on Physical Activity and Public Health. The Committee on Exercise and Cardiac Rehabilitation of the American Heart Association endorsed and supported these recommendations. The purpose of the present report is to update and clarify the 1995 recommendations on the types and amounts of physical activity needed by healthy adults to improve and maintain health. Development of this document was by an expert panel of scientists, including physicians, epidemiologists, exercise scientists, and public health specialists. This panel reviewed advances in pertinent physiologic, epidemiologic, and clinical scientific data, including primary research articles and reviews published since the original recommendation was issued in 1995. Issues considered by the panel included new scientific evidence relating physical activity to health, physical activity recommendations by various organizations in the interim, and communications issues. Key points related to updating the physical activity recommendation were outlined and writing groups were formed. A draft manuscript was prepared and circulated for review to the expert panel as well as to outside experts. Comments were integrated into the final recommendation. PRIMARY RECOMMENDATION: To promote and maintain health, all healthy adults aged 18 to 65 yr need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 min on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 min on three days each week. [I (A)] Combinations of moderate- and vigorous-intensity activity can be performed to meet this recommendation. [IIa (B)] For example, a person can meet the recommendation by walking briskly for 30 min twice during the week and then jogging for 20 min on two other days. Moderate-intensity aerobic activity, which is generally equivalent to a brisk walk and noticeably accelerates the heart rate, can be accumulated toward the 30-min minimum by performing bouts each lasting 10 or more minutes. [I (B)] Vigorous-intensity activity is exemplified by jogging, and causes rapid breathing and a substantial increase in heart rate. In addition, every adult should perform activities that maintain or increase muscular strength and endurance a minimum of two days each week. [IIa (A)] Because of the dose-response relation between physical activity and health, persons who wish to further improve their personal fitness, reduce their risk for chronic diseases and disabilities or prevent unhealthy weight gain may benefit by exceeding the minimum recommended amounts of physical activity. [I (A)]

Self-reported physical activity among blacks: estimates from national surveys.

BACKGROUND: National surveillance data provide population-level estimates of physical activity participation, but generally do not include detailed subgroup analyses, which could provide a better understanding of physical activity among subgroups. This paper presents a descriptive analysis of self-reported regular physical activity among black adults using data from the 2003 Behavioral Risk Factor Surveillance System (n=19,189), the 2004 National Health Interview Survey (n=4263), and the 1999-2004 National Health and Nutrition Examination Survey (n=3407). METHODS: Analyses were conducted between January and March 2006. Datasets were analyzed separately to estimate the proportion of black adults meeting national physical activity recommendations overall and stratified by gender and other demographic subgroups. RESULTS: The proportion of black adults reporting regular PA ranged from 24% to 36%. Regular physical activity was highest among men; younger age groups; highest education and income groups; those who were employed and married; overweight, but not obese, men; and normal-weight women. This pattern was consistent across surveys. CONCLUSIONS: The observed physical activity patterns were consistent with national trends. The data suggest that older black adults and those with low education and income levels are at greatest risk for inactive lifestyles and may require additional attention in efforts to increase physical activity in black adults. The variability across datasets reinforces the need for objective measures in national surveys.

Evidence-based interventions to promote physical activity: what contributes to dissemination by state health departments.

BACKGROUND: Evidence-based guidelines for promoting physical activity have been produced, yet sparse information exists on the dissemination of effective interventions. The purpose of this study was to better understand the dissemination of physical activity interventions across the United States, focusing particularly on evidence-based guidelines. DESIGN: A cross-sectional study was conducted in the U.S. that was organized around a modified version of the diffusion of innovations theory. SETTING/PARTICIPANTS: Respondents (n=49) were the physical activity contact person (e.g., program administrator, health educator) in each state or territorial health department. MAIN OUTCOME MEASURES: Seven specific programs and policies relating to physical activity intervention were examined as dependent variables. Five additional domains--organizational climate, awareness, adoption, implementation, and maintenance--framed a set of independent variables. RESULTS: The most important factor related to decision making was the availability of adequate resources. Most respondents (89.8%) were aware of evidence-based guidelines to promote physical activity. However, less than half of the respondents (41%) had the authority to implement evidence-based programs and policies. A minority of respondents reported having support from their state governor (35.4%) or from most of their state legislators (21.3%). Several key factors were associated with the adoption of evidence-based interventions, including the presence of state funding for physical activity, whether the respondent participated in moderate physical activity, presence of adequate staffing, and presence of a supportive state legislature. CONCLUSIONS: Awareness of the importance of promoting physical activity is relatively high in state and territorial health departments; however, the levels of internal support within the health department appear to outweigh any outside support from elected officials.

The effect of disseminating evidence-based interventions that promote physical activity to health departments.

OBJECTIVES: We explored the effect of disseminating evidence-based guidelines that promote physical activity on US health department organizational practices in the United States. METHODS: We implemented a quasi-experimental design to examine changes in the dissemination of suggested guidelines to promote physical activity (The Guide to Community Preventive Services) in 8 study states; the remaining states and the Virgin Islands served as the comparison group. Guidelines were disseminated through workshops, ongoing technical assistance, and the distribution of an instructional CD-ROM. The main evaluation tool was a pre- and postdissemination survey administered to state and local health department staffs (baseline n=154; follow-up n=124). RESULTS: After guidelines were disseminated through workshops, knowledge of and skill in 11 intervention-related characteristics increased from baseline to follow-up. Awareness-related characteristics tended to increase more among local respondents than among state participants. Intervention adoption and implementation showed a pattern of increase among state practitioners but findings were mixed among local respondents. CONCLUSIONS: Our exploratory study provides several dissemination approaches that should be considered by practitioners as they seek to promote physical activity in the populations they serve.