JPAH_Breckon2008

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Journal of Physical Activity and Health, 2008, 5, 398-417

2008 Human Kinetics, Inc.

Physical Activity Counseling Contentand Competency: A Systematic Review

Jeff David Breckon, Lynne Halley Johnston,and Andrew Hutchison

Background: Physical activity (PA) counseling is becoming commonplace inprimary care settings, although there is a high degree o variation in the quality

and quantity o this intervention. The purpose o this review was to examine the

theory on which the intervention is based and the level o treatment delity applied

at all stages o the intervention.Methods:A systematic review was carried out or

interventions that reported an element o PA counseling. Results were mapped

according to a treatment delity ramework o intervention design, training,

delivery, receipt, and enactment. Results: Most studies were underpinned by the

transtheoretical model. Few studies described the requency or duration o PA

counseling training or competence level o the interventionist. The most common

outcome measures were behavioral and physiological, with ew studies includinga cognitive outcome measure. Conclusions: Most research ocuses on outcome

and signifcance rather than intervention processes, with limited consideration

o treatment delity. The design, training, delivery, and receipt o PA counseling

should be reported more thoroughly.

Keywords: treatment delity, behavior change counseling

Despite the avorable health benets associated with regular physical activity(PA), inactivity levels in developed countries are alarmingly high.1 Many people arein a stage o chronic contemplation, and the methods applied to assist in resolvingthis state o ambivalence have traditionally centered on providing advice and educa-tion, although this has not resulted in signicant behavioral shits.2 An alternativestrategy, behavior change counseling, has been proposed, although research hasbeen slow to clearly identiy which behavior change counseling techniques workand why. Central to this issue is the clear specication o the critical techniquesand procedures responsible or behavior change in order that interventions can bereplicated and eect sizes accurately calculated.3 It has been suggested that theeectiveness o behavior change counseling might not simply be the result o who

delivers it but more so the length, the intensity, the content, and the competenceo the deliverer.4


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Physical Activity Counseling 399

Current Problems in PA Counseling

An increasing body o evidence supports the use o PA counseling in a variety

o primary, secondary, and community health care settings5-9 to the point that PAcounseling is becoming part o normal health care in the prevention, treatment, andmanagement o chronic diseases.10 There is, however, a lack o clarity and consis-tency in terms o what exactly PA counseling consists o and how it is delivered.

In the UK, the rst guidelines or conducting an exercise (or PA) consultationwere produced in 1995.11 Although these early guidelines lled a void, subsequentinterventions applying these principles have compromised and conused the originalguidelines.7,12,13 The accurate description o PA interventions are oten lacking withlittle or no detail as to the delity, and thereore quality, o the intervention. More-over, there is oten no standardized measurement o PA outcome, PA counseling

content, technique, or patient readiness and receptiveness to the intervention.6

In PA counseling, there is oten a theoretical model described as an adjunct tothe PA intervention,14 most common o which are sel-determination theory (SDT15),the transtheoretical model (TTM16), or a specic approach such as motivationalinterviewing.17 It has been proposed, however, that many behavior change descrip-tions are not specic about the intervention employed, and no clear link betweenthe theoretical underpinning and particular behavior change techniques employedis oered.3 In 1996, researchers were urging urther studies regarding the training,intervention design, and evaluation o primary care PA delivery,18 although this hasbeen slow to materialize. Thereore, a critical review o current exercise and PAcounseling interventions in clinical and community settings is required.

Treatment Fidelity and the Behavior Change Consortium(BCC) Framework

There has been an increasing call or researchers to ully articulate the exact natureo their interventions or behavior change counseling, an approach which is termedtreatment fdelity.19 Indeed, health behavior change research has or some timeembedded delity tests into counseling interventions and research20-22 to preserve

internal validity and enhance external validity in studies. However, this has tradi-tionally received scant attention in research journals and training curricula.23 Toaddress the issue o treatment delity or behavior change settings, a consortiumo health behavior change studies was gathered in the United States under the aus-pice o the National Institutes o Health Behavior Change Consortium (BCC). TheBCC group recommended 5 areas or implementing delity treatment measuresin behavioral trials. The 5 components are summarized as a need to encouragedelity at the design, training, delivery, receipt, and enactment stages. An applica-tion o this to the PA setting is considered within the strategies or achieving eachcriterion (Table 1).

It is important to examine the potential ecacy o health behavior change del-ity measures to ensure reliable, valid, and robust interventions based on sound theo-retical and scientic principles Only by developing more powerul scientically


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400 Breckon, Johnston, and Hutchison

Table 1 Treatment Fidelity Components and Exercise Counseling

Applications

Componentof treatmentfidelity Definition and description

Application to an exercisecounseling intervention

Design Treatment delity is applied atthe design stage to ensure that theintervention can adequately testthe proposed hypotheses. This isin relation to underlying theoryand clinical processes.

Intervention consistent withbehavior change theorysuch as stages o change,sel-determination, or sociallearning theory. Clear exer-cise counseling protocoldeveloped.

Training To ensure that those deliveringthe intervention have been sat-isactorily trained, assessmentis carried out o their skills andcompetencies in relation to thestudy.

A combination o supervisedrole-playing, clinical supervi-sion, and reviews o audio-tapes applied as an adjunct toa training manual.

Delivery Treatment delity processes areapplied to monitor that the inter-vention is delivered in line withthe proposed design.

Exercise counseling inter-ventions audiotaped andreviewed using a behavioralchecklist based on the studyprotocol. Correction o

observed intervention devia-tions.

Receipt The ocus is toward the recipiento the intervention. The delityacet here aims to ensure that theintervention or treatment receivedis understood by the individualand that they can apply the inter-vention at a cognitive and behav-ioral level.

Evaluation o the eects othe exercise counseling inter-vention using postsessionquestionnaires or interviews(cognitive) and checklisto participant strategiesemployed (behavioral).

Enactment An analysis is taken o theapplication o the treatment bythe individual. This monitor-ing ensures that behavioral andcognitive strategies are applied inreal-lie settings.

Completion o interventionstrategy goals specic tothe study outcomes. Clientsencouraged to record accu-rately completed and missedsessions and to report occur-rences o relapse.

Treatment delity, thereore, plays a central role in ensuring that an interventionhas been accurately evaluated. A recent synopsis o research projects into behaviorh d li h d h d li i l i


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more in-depth description o each delity goal, description, and strategy, the readeris reerred to the BCC guidelines.23

The current article, thereore, uses the BCC ramework or treatment delity

to examine, by way o a systematic review, the detail reported in PA counselinginterventions. It then reports implications or uture interventions and oers guide-lines or designing and implementing PA counseling interventions.

Why a Systematic Review?

A variety o interventions that have included a PA component have been appliedin clinical and community settings. To assess the quality o these interventions, asystematic review o PA counseling studies was carried out to

assesstheimpactofPAcounselingonbehaviorchange,

identify the extent to which PA counseling adopts a treatment fidelityapproach,

review the use ofunderpinning theoretical models and frameworks inthedevelopment o the intervention,

criticallyexaminetheinterventionistandleveloftrainingbeforethedeliveryo the intervention,

identifytheopportunityfortheadoptionofdelitytreatmentatallstagesofthe research process, and

examinetheoutcomesmeasuredandtheresults(eg,epidemiological,behav-ioral, and cognitive).

Methods

Selection of Studies for Inclusion

Two main sources were used to locate published studies: (1) electronic searches ocomputerized databases including SPORTdiscus, Psychino, Sciencedirect, Cinahl,Web o Science, PubMed and Scopus and (2) citations in papers identied by theelectronic search. The review was interested in interventions that included an ele-ment o PA counseling and that required personal interaction, patient centeredness,and sound communication. Even though online and telephone adaptations areincreasing in popularity, ace-to-ace counseling studies were selected because theyremain the dominant approach in PA settings. The review did not ignore methodssuch as telephone contact because a number o reviewed studies included telephoneollow-ups. The rst exercise and PA counseling guidelines in the UK11 logicallyprovided the lower date limit or the current search (1995). Key search terms werephysical activity counseling, physical activity consultation, exercise counseling,

and exerciseconsultation. Articles retrieved using these search terms were includedin the review i they met the ollowing criteria:

1 English language


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consultation and not as an adjunct to a larger behavior change interventionor in conjunction with other liestyle behaviors (Trials in which the physicalactivity counseling or consultation is conducted as part o a larger intervention

or in conjunction with another health behavior cannot demonstrate the absoluteeect o the exercise counseling or consultation.)

4. Individually adapted (ie, not group), ace-to-ace (ie, not telephone or mail)behavior change interventions

5. Interventions that aim to increase physical activity and include behavioral orcognitive outcome measures (the eect o a physical activity behavior changeintervention can be measured by observing dierences in physical activitylevels or by evaluating cognitive processes that determine behavior change[eg, stage o change, sel-ecacy, perceived benets o physical activity])

6. Publication between 1995 and 2006 inclusive7. Adult population (age 16 years)

Procedure

Searches generated a total o 924 articles. Ater duplicates were removed, 76abstracts were retrieved. Forty-six abstracts were deemed relevant, and ull-textarticles were obtained. Closer inspection o these identied that 27 were relevantor inclusion in this review. Hard copies o those publications that met the inclusioncriteria were analyzed based on the aims o the review. The process was applied

independently by JB and AH to ascertain whether studies met the inclusion cri-teria. Any discrepancies between the reviewers were agreed by discussion o theoriginal papers and, where necessary, the use o LH as a moderator. Main outcomeswere analyzed as were theoretical rameworks and treatment delity regimens oreach study. Once selected, corresponding authors were contacted to ully examineprocedures (regarding PA counseling training and competence). This was done toclariy whether the PA counseling competence had been assessed though omittedbecause o page limits, assessed and published or reported elsewhere, or whetherno assessment o practitioner PA counseling competence had been applied.

Data Extraction

In addition to the quality assessment o each study, the ollowing data were extractedusing a structured orm (Table 2): design, treatments, consultation (theoreticalramework), consultant (interventionist), intensity (and ollow-up), duration, train-ing and competence assessed, outcome measures, and outcome results. Based onthe BCC ramework, a descriptive account was ormulated to identiy the strengthsand weaknesses in the literature, with specic reerences to the BCC componentso treatment delity (Table 1).

Results


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were received rom 13 o the 27 (48%) studies authors. As a result, 1 study26 waseliminated ollowing additional detail and clarication o its methods rom theauthor. Table 2 shows a summary o the main characteristics o the remaining

studies that met the inclusion criteria.Some studies did involve telephone counseling as part o the intervention.27-29

However, because the main counseling intervention was ace to ace, these stud-ies were included. Although the search criteria were or studies between 1995 and2006, only 1 o the included studies was published beore 2000.30 Fiteen o the26 studies (58%) included were published ater 2003.

Outcome for Design and Treatment

RCTs were ound to be the dominant design. These ollowed a very prescriptive,

positivistic (medical model) approach with cause-and-eect outcome measuresdened within behavioral dimensions and time constraints. When mapping theBCC ramework or design, same treatment dose is assumed, but none o thestudies highlighted how this was achieved nor the strategy employed. Althoughsome oered good descriptions o the interventions involved,31-33 some merelyidentied a style or ramework such as motivational interviewing30,34 or the 5 Asramework,29,35 with very brie descriptions o the methods. In some cases detaileddescriptions regarding the processes involved in the interventions were included,such as setting goals or planning or uture barriers.27,36 No studies providedinormation regarding the specic interpersonal style or core conditions othe counseling interventions (eg, client centered, empathetic understanding, orcongruence and understanding37).

Outcome for Counseling Type, Provider, and Training

A wide variety o descriptive terms were used to dene the type o counseling usedin each study. The most common were counseling31,32 andphysical activity counsel-ing,38 although terms such as brie advice,27behavioral counseling,39 andphysicalactivity consultations40 were also used. The lack o consistency in describing theexact nature o the counseling delivered made it dicult to identiy dierencesbetween interventions. In some studies researchers even used multiple terminologiessuch as counseling and consultation when describing the same intervention.12,32

The providers or interventionists in the reviewed studies represented research-ers,38,40 primary care workers,28,41 exercise scientists,8 and other health proession-als.34 A number o studies ailed to identiy who the intervention was deliveredby.39,42-44

O the 26 studies, 15 (58%) identied that providers received training (eg,29,35,36).However, only 7 o these13,27,29,35,36,45,46 included any inormation concerning the re-quency, duration, and content o training. O those 7 studies, training ranged rom 1

session o 45 minutes

29

to 11 hours o training spread over 4 sessions.

45

Followingthe review (and author eedback), 5 studies27,35,24,45,46 administered and reported thetraining and competence o the interventionist. These involved checklists,27 review-


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ystem

aticReview

ofStudies

IncludingaPhysicalA

ctivityCounselingCom

ponent

r

Jo

urnalDesign

Treatments

Consultation

(theoretical

framework)

Consultan

t

(interventionist)

Competenceof

interventionist

assessed

(Yes/No)

Intensity

Study

duration

Outcom

e

measures

Outcomes()

9

BM

J

RCT

Brievsintense

counselingwith/

withoutvouch-

ers,control

MI

Healthvisitor

trainedinMI

No

1session(40min)

/6sessionsover

12wk

12mo

Behavioral

Nosig.

eects

0

Am

J

Prev

Me

d

RCT

Cognitivebehav-

ioralinterven-

tion,knowledge-

orientated

intervention

(control)

Lecturesbased

onTTM,SCT

withollow-

upcounseling

phonecalls

Trainedbehav-

ioralscienceac-

ultymemb

ersand

counselors

No

50minweekly

or15

wk,phone/

mailollow-ups

or18

mo

24mo

Phys

Nosig.

eectsorPA

outcomes.

Behavioral

processeso

change(+)

orinterven-

tionwomen

0

Prev

Me

d

RCT

PACEcounsel-

ingprotocolwith

reminderphone

callsorusual

care

PACEcounsel-

ingprotocol

basedinTTM

Trainedph

ysician

(providedwith

PACEtrain

ing

manual)

Yes

1session,

unkno

wnduration

6mo

Cognitive,

behavio

ral,

&phys

Nosig.

eects

1

JAMA

RCT

Advice,advice

pluscounseling

,

advicepluscou

n-

selingplustele-

phonesupport

Brieadvice

basedon

nationalrecom-

mendations

Physicians

/health

educatorstrained

byACTbe

hav-

ioralscientists

Yes

130

40-min

sessio

nplus1

teleph

onecall,

urthe

r2weekly

(6wk)andthen

month

ly(1yr)in

intens

egroup

24mo

Behavioral

&phys

VO2max(+)

orassistance

andcounsel-

inggroupsvs

advicegroup


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1

Diabetic

Me

d

RCT

Exercconsulta-

tion&exerc

inormation,

orinormation

alone

One-on-one

discussionbased

onTTM

Trainedresearch

assistant

No

130

min

5wk

Behavioral

&cogn

i-

tive

Sig.progres-

sionacross

stageso

change&(+)

inactivity

countsor

consultation

groupvs

controls

1

Psych

Sport

Exerc

Quasi-

Experi-

mental

Inormation/

actionsordaily

lieactivities/

tnesssessions

/

counseling

Counselingno

urtherdetails

ExercproessionalNo

Appr

oximately

every

3wkor

4mo

4mo

Cognitive

&behav-

ioral

Sig.progres-

sionacross

thestageso

change

2

Int

J

Epid

RCT

DirectAdvice,

BN,control(no

intervention)

Clearlydened

BN

Healthpromotion

specialist

No

130

minwith6

teleph

oneollow-

ups

12mo

Behavioral

&phys

Nosig.

eects

2

JC

ar-

dio

-pul-

mo

nary

Rehab

RCT

Exercconsulta-

tion&standard

exercleafet,or

leafetalone

Consultation

/counseling

matchedto

stageoexercise

behaviorchange

Researcher

No

130

min

17wk

Behavioral

Short-term

adherenceto

PA(+)or

consultation

group

2

JS

port

Sciences

2R

CTsFitnessassess-

ment/control,

exercconsulta-

tion/control

Consultation

inaccordance

withLoughlan

&Mutrie(1995)

Researcher(ol-

lowedasta

ndard

consultatio

norm)

No

130

min

12mo

Behavioral

PA(+)or

thosereceiv-

ingexerc

consultations

(continued)


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r

Jo

urnalDesign

Treatments

Consultation

(theoretical

framework)

Consultan

t

(interventionist)

Competenceof

interventionist

assessed

(Yes/No)

Intensity

Study

duration

Outcom

e

measures

Outcomes()

3

JC

lin

Epid

RCT

6modulediet

andPAprogram

.

High-level:3

groupsession/3

mailed,low-

level:allmailed,

control:nointe

r-

vention

Inormed-based

interactive

approachto

groupsessions

Unknown

No

3contactmodules

in16wk

12mo

Phys&

behavio

ral

Physical

tness(+)

&epidmea-

sures(-)in

thehigh-level

group

3

Am

J

Prev

Me

d

RCT

Individualcoun-

selingorwritte

n

inormation

PACEcounsel-

ingprotocol

basedonTTM

Trainedph

ysio-

therapist

(GivenPACE-

relatedwritten

materials)

No

Upto

72

0min

9mo

Phys&

behavio

ral

Energy

expenditure

(+),PA

duringsports

(+),cardio-

respiratory

tness(+),

%at(-),and

bloodcholes-

terol(-)or

theinterven-

tiongroup

4

Nu

tri-

tion

RCT

2-phased

Phase1:exerc

onlyorexerc

plusdiet,Phase

2:notreatment

Counseling

inaccordance

withprinciples

putorthby

theAmerican

Collegeo

SportsMedicine

(ACSM)

Exercphysiologist

/dietitian

No

Weekly(phase1)

12/24wk

Phys&

cognitive

Weight&

BMI(-)or

diet/exerc

groupbutnot

orexerconly

group.Fat

mass&waist

circum(-)or

bothgroups

ntinu

ed)


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4

Am

J

Prev

Med

RCT

Standardleafet

pluscounseling,

orleafetalone

Counseling/con-

sultation(multi-

pleterminology)

basedonTTM,

motivational

theory/CBT

Trainedresearch

assistant

No

230

min(base-

linean

d6mo)+2

telephoneollow-

ups(1

and3mo)

12mo

Behavio

ral

&cogni-

tive

PAlevels(+)

inexperimen-

talgroup

4

Dia

be-

tolg

ia

RCT

Standardleafet

pluscounseling,

orleafetalone

PAcounseling

wasconducted

inaccordance

withLoughlan

&Mutrie

(1995).

Trainedresearch

assistant

No

130

min

12mo

Behavio

ral

&phys

PA(+)in

experimental

groupvs

control

4

IntJ

Nurs

Studies

Quasi-

Experi-

mental

Exercconsulta-

tionpluspre-

scription,stan-

dardeducationa

l

advice(control)

Stage-matched

exerccounseling

strategy

Researcher

No

16090min

withte

lephone

ollow-upstwice

weekly

3mo

Cognitive,

behavioral,

&phys

PAlevels

(+),epid

measures(-)

ininterven-

tiongroupvs

control

4

Hea

lth

Psy

ch

RCT

PAcounsel-

ing,PAplus

dietcounseling,

control

Modiedversion

oPatient-Cen-

tredAssessment

andCounseling

orExerc

Unknown

No

130

min

3mo

Behavio

ral

PA(+)or

boysbutnot

girls

4

Pat

Ed

Couns

RCT

Counseling,

counselingplus

tness,control

Goal-setting,

advicegiving,

basedonTTM,

supportingsel-

ecacy

Occupation

al

nurses,rece

ived

11hrotraining

(trainingha

nd-

bookprovided)

Yes

4sessions

baselin

e,8wk,6

and12

mo

12mo

Behavio

ral

&cogni-

tive

Nosig.

eects

(continued)


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r

Jo

urnalDesign

Treatments

Consultation

(theoretical

framework)

Consultan

t

(interventionist)

Competenceof

interventionist

assessed

(Yes/No)

Intensity

Study

duration

Outcom

e

measures

Outcomes()

5

JS

ci

Me

d

Sport

RCT

Brieverbaland

writtenadvice,

counselingand

ollow-upphon

e

callswithor

withoutapedom-

eter

TailoredPA

counseling

GPverba

l&

writtenadv

ice,

exercscien

tist

counseling

No

1sessiono

1520

min

24wk

Phys

Nosig.

eects

5

PatEd

Co

uns

RCT

Adviceplus

counselingses-

sion,control

Flexibledepend-

ingonstageo

change(moti-

vation/action

orientated),no

modelgiven

Physicians

&

practiceassistants

with6-hrtraining

(manualou

tlining

counseling

proto-

colprovided)

No

145

min+3

phone

ollow-ups

14mo

Behavioral

PAincreased

orboth

intervention

groups.No

between-

groupeects,

5

Prev

Me

d

RCT

Combinedexerc,

diet,andbreast

healthinterven-

tion

Teaching/sup-

portingPAbased

onsocialcogni-

tivetheoryplus

exerctraining,

control

Unknown,

trained

interventio

nist,

certiedby

master

trainer

Yes

45-minsession

(allco

mponents)

onceperweekor

20wk

20wk

Phys&

behavio

ral

PA(+)or1

intervention

groupvs.

control

5

PatEd

Co

uns

RCT

Advice/support

onincreasingP

A

topromotehealth

(patientswithout

hypertension)

ortoreducerisk

actor(hyperten-

siongroups),2

controlgroups

Negotiationo

preerredactiv-

ityplusadvice,

bookletson

behaviorchange

Physiciantrained

oreither1

hr

(individually)or

23hr(gro

up

trainingsessions)

No

1session

unkno

wnduration

6mo

Behavioral

Nosig.

eects

ntinu

ed)


12/21

5

Prev

Me

d

RCT

Weightmanage-

mentprogram,

behavioralcoun-

seling,nutrition

education,exer

c

sessions

Basedonprin-

ciplesandpro-

cessesoTTM,

stage-specic

strategies

Unknown,

trained

interventio

nist

No

2-hse

ssions/wk

or3mo,8ses-

sionsinnext3

mo(notexercise

speci

c)

24mo

Phys,

behavio

ral,

&cogn

i-

tive

Epidmea-

sures(-)&

PA(+)

5

Am

J

Prev

Me

d

RCT

Brieadvicewith

ollow-uptele-

phonecounseling

orbrieadvice

alone

HBCbasedon

5Asramework

tailoredto

patientsstageo

readiness

Medicalstudents

&generalinter-

niststraine

dor

45min

No

3ace

-to-ace

PAco

unseling

sessio

ns,12PA

counselingphone

calls

9mo

Phys&

behavio

ral

Participa-

tion(+)in

extended

advicegroup

vsbrie

advicegroup

5

JA

m

Ge

riat-

ricsSoc

RCT

PAcounselingor

controlgroup

Brieactivity

counseling

Primaryca

redoc-

torsorpractice

nurses

No

1session,

unkno

wndura-

tion,3

ollow-up

phone

calls

12mo

ollow-

up

Phys&

behavio

ral

Activ-

itylevels

&energy

expenditure

(+)between

intervention

group&

control

6

Prev

Me

d

RCT

Prescription-

basedcounseling,

sel-monitoring

orcontrol

Physicalactivity

counselingbased

onthe5As

ramework

Physicians

trained

or2hr(user

guideswer

epro-

vided)

Yes

1session,

unkno

wnduration

6mo

Behavioral

&phys

PA(+)or

intervention

groupvs

controls

6

PatEd

Co

uns

RCT

Regularrehab

programplus4

counselingses-

sionsorregular

rehabonly

Counselorsol-

lowedthegen-

eralprinciples

oMI

Physicalth

erapist

No

4sessionso30

minspreadover

11wk

911wk

Phys,cog-

nitive,&

behavio

ral

PAlevels(+)

orexperi-

mentalgroup

vscontrol

PA,physicalactivity;HBC,healthbehavio

rcounseling;TTM,transtheoretic

almodel;SCT,socialcognitivetheory;BN,brienegotiation;MI,m

otivationalinterview-

ological;BM,bodymass;exerc,exercise;circum,circumerence;sig.,sign

icant;GP,generalpractitioner;(

+),signicantincrease;(-),signi

cantdecrease.


13/21


Outcome for Intensity, Frequency, and Durationof Counseling Delivery

Some studies involved just one 30-minute consultation,40,43

whereas other studiesinvolved much more intensive counseling containing multiple sessions and ollow-up phone calls.29 Intervention durations ranged rom 9 weeks to 24 months. However,PA counseling was usually conducted in the rst 3 months,36,47 with ollow-ups rang-ing rom 4 weeks12 to 24 months.27,39,48 There appears to be no consensus regardingappropriate intensity, requency, or duration o counseling interventions.

Outcome Measures and Results

For the purposes o this review, outcome measures were categorized into either

physiological (eg, heart rate [HR], blood pressure [BP], body mass index [BMI]),behavioral (adherence), or cognitive (perceptions) outcomes. Most studies includedoutcome measures rom more than one category. The most common outcomemeasures were behavioral (eg, PA questionnaires48,49) and physiological (eg, HR,BMI8,44). Only a very small proportion o the reviewed studies included cogni-tive outcome measures (ie, stages o change questionnaire,49 processes o changequestionnaire,39 decisional balance measures,39 or sel-ecacy measures34). Six othe studies28,30,33,45,46,47 reported no signicant change across their sample rom PAcounseling. Thirteen studies reported a behavioral change (increased PA) in at least1 intervention group (eg,9,13,31,32,40), although only 3 studies reported a cognitive

shit.13,48,49All o the remaining studies reported a physiological or epidemiologicalchange (such as reduced BMI8 and increased VO

2max27) in participants between at

least 1 intervention group and a control. Only 5 studies reported having applied anyorm o treatment delity.27,35,42,45,46 Three reported signicant results,27,35,42 with theremaining 2 reporting no dierences as a result o the intervention(s).These ndingsrefected the equivocal nature o the results across the range o reviewed studies.

Discussion

The review suggests a purposeul shit away rom research that is purely outcome

ocused, positivistic, and with an emphasis on physiological outcomes. Moreover,there appears to be an increased awareness o the need to embed cognitive andbehavioral components into PA behavior change with an appreciation o the needor greater motivation and support or PA and liestyle change beyond merely adviceand education.10 Indeed, the delivery o PA counseling interventions within primaryhealth sectors involving allied health proessionals has occurred as a result o publichealth initiatives and policy.5 However, health care systems have limited budgetsand as a result cannot be expected to continue to und and develop interventions thatail to address treatment delity issues. Results o the current review highlightedthat none o the PA counseling interventions have addressed treatment delityissues. At best, PA counseling interventions reviewed here indicated a theoreticalunderpinning but did not ully articulate the application o theory to practice by


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Intervention Designs

The BCC ramework raised awareness o the need or a greater integration o

theory to practice. It highlighted the importance o a clear design and theprocessesinvolved, not just the outcomes that result. Many o the interventions did providesome outline o the underlying theoretical construct on which the intervention wasbased, the dominant model being the transtheoretical model (and stages o change).Several studies cited the Loughlan and Mutrie guidelines and an approach basedon the stages o change and the transtheoretical model.7,12,13,32,38 Although thisprovides a theoretically grounded approach, it does not inorm practitioners on howto interact with the client, elicit their perceptions o the need and desire or change,and how to deal with issues such as ambivalence and resistance. This illustratesthat the original 1995 guidelines11 have not been accurately applied and that the

therapeutic alliance has been diluted or ignored altogether. Only the 5 As51 hadbeen presented beore 1995. These were again outlines owhatto include ratherthan how to apply the content. The search considered these guidelines by expandingthe search rom 1992 (rather than 1995) using the same inclusion criteria. However,no additional studies resulted rom 1992 onward, and thus 1995 remained as thesearch start date.

The dominance o RCT designs is clearly illustrated in the current review (83%o the studies) and emphasizes the research preerence or control o variables andcontrol o extraneous actors. Although, this does not refect well the diverse nature(and reality) o community settings where most PA interventions are delivered, and

the lack o ecological validity in RCT designs is a major concern and might notrefect real-lie situations.52 Nor do RCTs ensure high-quality delivery o interven-tions, even though there is an implicit assumption that because the intervention ispart o an RCT design, it is standardized.

Training and Delivery

The internal and external validity acets o behavior change interventions areundamental or methodological rigor. However, scant attention is paid to these inresearch-training curricula, and there is a perceived lack o importance in published

research.23 Indeed, it has been suggested that without understanding these issues,researchers and clinicians application o behavior change technologies is likelyto be slow, with wheels being re-invented rather than re-applied.3(p.30) However,in-service training o general practitioners in the Unites States and UK has shownthat a systematic patient-centered protocol or PA promotion is ecacious.5 Seveno the studies reviewed described the intensity, requency, or duration o trainingin PA counseling delivered to those providing the intervention. Although thesesuggested that the interventionists had acquired the appropriate skills, or a level ocompetence in the application o these skills, it is not clear how robust the assessmentactually was. When compared with loose guidelines or recommendations that arenot underpinned with provision or training into the how and whatto deliver, clearprotocols might remove ambiguity inherent in PA counseling.53 There is a limited


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Receipt and Enactment

The BCC ramework highlights the importance o ensuring the acquisition o

behavior change skills and techniques by the recipient (eg, client or patient). Thiswould ensure that the counseling recipient understands, and is able to enact, thetechniques discussed in an action-planning phase o PA counseling. Although thisis key to creating an autonomous and independent individual, no studies reportedhow well the recipient understood the intervention delivered and their ability toapply it both cognitively and behaviorally. The most common outcome measureswere behavioral and epidemiological (18 studies), with only 6 o the reviewed stud-ies including a cognitive outcome measure that might enable an assessment o thecognitive receipt and/or enactment. Other aspects such as PA and health-inormationrecall could have been applied within ollow-ups considering the relatively high

number o studies that applied this design (eg,8,30,45).Equivocal results (both behaviorally and physiologically) have resulted rom

PA counseling interventions. It appears that studies have not ully analyzed (orreported) the design, training o interventionists, quality o delivery o the interven-tion, receipt o the intervention by the patient, and the patients ability to enact thenew strategy. It is imperative that studies ully report not just what they have donebut also embed monitoring and evaluation o how eective the intervention wasat all stages. Only when this is commonplace can practitioners have condence inPA counseling techniques.

Although many substance addiction and health psychology interventions are

applying practitioner measures o competency, such as the behavior change counsel-ing index (BECCI56), PA counseling has been slow to do so. The BCC rameworkmight help to explain more accurately why an intervention has succeeded or not.However, although there appears to be an unequivocal argument or increasedtreatment delity and consistency across health behavior change interventions,a note o caution has been sounded by some authors, suggesting the demand ordelity testing might be inappropriate or all steps.53 The authors purport that theapproach suggested by the BCC group ignores 2 things: rst, that there are ewtheoretically grounded empirical studies o the processes involved in the success-ul attainment o this sequence, and second, that trials with perect delity might

produce evidence that lacks a conceptual basis or adaptation across dierentdiseases, treatments, patients, practitioners, institutions, and cultures and might,thereore, lack applicability in clinical practice. In light o this, it is important orbehavior change interventions to identiy the core principles o treatment delity thatare undamental to achieving high-quality interventions through research design,interventionist training, and delivery, to client receipt and enactment. However,although the BCC strategies might appear exhaustive and potentially restrictive,53the BCC approach is based on validity and reliability checks rom other counsel-ing settings and oers a ramework that has never been applied within the contexto PA counseling.

Implications for Policy Practice and Training


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which are increasingly looking to address behavior change but have oten basedtheir evidence, and subsequent training program content, on studies that ail toconsider treatment delity issues. Although the treatment delity approach might

provide clearer guidance on the training and techniques required, there is a need ora greater understanding o (1) how dierent orms o implementation o motiva-tion aect training proessionals, (2) how a proessionals style o delivery aectsreception, and (3) how and whether dierences in reception aect dierences inenactment.53 This may be achieved by using specialists with greater experience andassessed competency in PA counseling. Indeed, it has recently been suggested thatspecialist PA counselors be trained and reerred to rom allied health proession-als and physicians because they oer the potential to be more eective because otime and knowledge issues.4

It is clear that studies incorporating PA counseling do not currently adhere toa ramework or treatment delity, and this inevitably had an impact on the qualityo the interventions at all stages. There is certainly value in the 1995 guidelines,11although subsequent studies (eg,8,57) have ailed to adequately apply a detailedprotocol or ramework or the PA consultation. I delity treatment measures (suchas the BCC ramework) are not applied to such settings, then it appears reasonableto suggest that studies need to explain and ully justiy why they have not beenapplied and to report alternative saeguards or quality assurance. There needs to bea greater understanding o the processes involved in the clientPA proessional rela-tionship. Examples already exist in the addictions setting in which psycholinguistic

research

58

has explored process variablesa paradigm shit that PA counselingshould consider. Recent calls have been made or an increase in RCT studies thatinclude a PA counseling component.59 However, this would currently have to occurin a research environment where the intervention is not ully understood. A greaterawareness then o the style o the interaction, and the relationship between the PAspecialist and client, might acilitate greater sel-awareness and change talk romthe client and provide a more appropriate, client-centered, PA consultation. Futureresearch should consider the application o rameworks such as the BCC in PAsettings and emphasize trainer competency, patient receipt o the change strategy,and a consistent PA counseling protocol that has treatment delity at its core.

Review Limitations

The authors considered the value o a qualitative versus quantitative methodologyor the review. Although examples o the latter60 might have oered a succinctnumeric alternative, the authors elt that the use o the BCC ramework togetherwith a detailed qualitative analysis oered a richer, more thorough, review. As aresult, the current qualitative method assessed the aims o this systematic reviewappropriately. A second issue was the choice o inclusion criteria o studies report-ing to have applied ace-to-ace PA counseling. Increasing economic and time

constraints have led to an increasing popularity o telehealth counseling (eg,Internet, video transmission, telephone), although it is the telephone that is by ar


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