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http://slidepdf.com/reader/full/60809909 1/29

Exercise DVD Improves ExerciseExpectations in CardiovascularOutpatients

Kristin S. Vickers, PhD; Mary A. Nies, PhD, RN, FAAN, FAAHB;Ross A. Dierkhising, MS; Simone W. Salandy, MPH; Marwan Jumean, MD;Ray W. Squires, PhD; Randal J. Thomas, MD; Stephen L. Kopecky, MD

Objective: To assess impact ofexercise education intervention onexercise frequency and attitudes.Methods: Cardiovascular outpatients(N=509) were randomized toreceive an education DVD or standardcare. Outcome measures(baseline and 6 weeks) assessedexercise frequency and cognitivevariables. Results: There was nodifference between groups on exercisefrequency change frombaseline, but DVD group reportedgreater exercise outcome expecta

RRegular physical activity is necessaryfor cardiovascular disease riskreduction,1 and lack of exercise hasbeen identified as a leading preventablecause of death.2 Despite the important

Kristin S. Vickers, Section of Patient Education;Ross A. Dierkhising, Division of BiomedicalStatistics and Informatics; Ray W. Squires, CardiovascularHealth Clinic; Randal J. Thomas, CardiovascularDiseases; and Stephen L. Kopecky,

Cardiovascular Diseases, all from Mayo Clinic,Rochester, MN. Mary A. Nies and Simone W.Salandy, College of Health and Human Services,University of North Carolina at Charlotte, Charlotte,NC. Marwan Jumean, Tufts Medical Center,School of Medicine, Boston, MA.

Address correspondence to Dr Kristin S. Vickers,Section of Patient Education, Mayo Clinic, 200First Street SW, Rochester, MN 55905. Email:[email protected]

tions than control group (P=0.01).There was a greater increase inrelapse-prevention behavior in theDVD group, compared to control,for those with low relapse-preventionbehavior at baseline (P=0.02).Conclusion: A minimal interventionimproves outcome expectationsfor exercise.

Key words: physical activity,DVD, relapse prevention, outcomeexpectations for exercise, videoeducation

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health benefits of exercise, the majorityof US adults do not engage in regularleisure-time physical activity.3 Consequently,

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interventions that effectivelyincrease the adoption and maintenanceof physical activity remain a public healthpriority.4 Within the American Heart Associationscientific statement on physicalactivity intervention studies, the authorsconclude that physical activity interventionstudies have demonstratedmoderate effects, but with heterogeneityacross studies and with little evidence

forlong-term maintenance of interventioneffects.1 Although physical activity interventionresearch has increased substantiallyover the past 2 decades, there remainsa need for the development andstudy of innovative interventions, includingthose delivered within a health caresetting and those delivering interventioncontent other than in a face-to-face for-

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Exercise Expectations

mat.1

Although face-to-face interventions (ie,a clinician/exercise counselor meetingwith an individual or group to providephys

ical activity intervention content)have demonstrated efficacy,5,6 there arebarriers to implementation in clinicalpractice including clinician time, clinicianperception of lacking skills and abilityfor exercise counseling, patient schedulingaround other responsibilities, transportation,cost, and inconvenience.7-9 Consequently,recent physical activity interventionshave included print materials,7tailored telephone messages generatedby a computer expert system,7,10 orhandheld computer technology11 to reduce

or enhance direct clinician contacttime and increase convenience. Amongthe various technologies used in exerciseinterventions, video-delivered physicalactivity education has received lessattention. There are, however, some distinct benefits of video-delivered education,including the feasibility of homeviewing given that the majority of USadults owns a digital video disc (DVD)player (83% overall, though only 48% forthose 65 and older)12 and that home viewingcan be convenient in terms of schedulingand location. Further, studies showthat video can be particularly effective inmodeling health behavior for the view

er13,including modeling of exercise.14,15 Althoughresearch in this area is limited,video media do appear to be an effectivemeans of delivering exercise content,16and because it has the potential to addressmany of the barriers to face-to-facephysical activity interventions in clinicalpractice, the impact of exercise educationdelivered via DVD requires additionalstudy.

Modeling or observational learning,which typically involves viewing anotherperson performing a behavior, is an importantaspect of self-efficacy.17 Accordingto social cognitive theory,17,18 self-efficacy(confidence in ones ability to overcomebarriers and take action), goals, and outcomeexpectancies (anticipated outcomeof engaging in a behavior) impact thelikelihoodthat a person will change ahealth behavior and that people learn notonly from their own experiences, but alsoby observing the actions of others and theresulting benefits of those actions.18 Socialcognitive theory has influenced numeroustheory-based physical activity

interventions,19 and self-efficacy has beenempirically supported as a mediator ofphysical activity frequency.20 Consequently,modeling, which can be successfully

incorporated into video interventions,is an important part of increasingself-efficacy, and self-efficacy is known toimpact physical activity. We are aware ofonly one prior study assessing the impact

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of an exercise education video on selfefficacy.15 In that study, patient modelsdemonstrated and verbalized increasedconfidence to engage in an exercise test(peak oxygen uptake exercise tolerancetest) and provided strategies to cope withthe discomfort of the exercise test. Participantsrandomly assigned to watch thevideo reported significantly higher self-efficacy than did those in the controlcondition.15

In addition to improving self-efficacy,video-delivered exercise education mayimpact cognitive behavioral factors previouslyassociated with increased physicalactivity frequency, such as exercise stageof change, exercise outcome expectations,goal setting, and relapse prevention.19 Inthis study we assess the impact of apatient education physical activity DVDthatwas designed with these cognitivebehavioral factors in mind. The videocontent is organized according to stagesof change, includes real people of differentages and body types talking about anddemonstrating their personal experiences(mo

deling) in adopting physical activity byovercoming barriers, solving problems,setting goals, and getting back on trackafter a lapse in activity (relapse-preventionbehavior). Although the barriers toexercise are discussed, there is emphasison the positive benefits these peopleexperienced with increased activity (positiveexpectations for exercise).

In this study we assessed the impact ofa patient education physical activity DVDon exercise frequency, exercise stage ofchange, exercise self-efficacy, outcomeexpectations for exercise, and goal-settingand relapse-prevention behavior. Weexpected that at follow-up, participantsrandomized to receive the video would

report increased exercise frequency, moreprogression in stage of change for exercise,greater exercise self-efficacy, morepositive outcome expectations for exercise,and more goal-setting and relapse-prevention behavior than did those in thecontrol condition. Because participation

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Vickers et al

was not limited to sedentary individualsor those motivated toward increased physicalactivity, and because cognitive variablessuch as stage of change for exercisemay be moderators of the relationshipbetween

exercise intervention and exercisefrequency,21 we anticipated that theimpact of the intervention may depend onbaseline level of physical activity frequency,exercise stage of change, or tendencyto give up if not initially successfulwith behavior change (relapse prevention).

METHODS

The study was approved by the MayoClinic Institutional Review Board.

Participant eligibility. All adult (18years of age or older) Mayo Clinic CardiovascularHealth Clinic (CVHC) patientswho attended their scheduled clinical visitduring the 3-month study enrollment periodwere invited to participate in thestudy. As standard clinical practice withintheCVHC, all patients receive cardiovascularrisk profiling and suggestions forregular physical exercise. Consequently,prior to participation in the study, participantshad received clinical recommendationsfor adopting and maintaining regularphysical activity. Study inclusion criteriawere as follows: CVHC patient who

(1) had attended scheduled clinical visit,(2) was over the age of 18 years, (3) waswilling to provide informed consent forparticipation, and (4) was able to completewritten forms in English. We excludedpatients not meeting the inclusion criteriaand those who had clinician-reportedclinical contraindications for exercise.All CVHC clinicians were made aware ofand reminded of the study and were askedto provide the study assistant at CVHCthe names of patients who were told not toexercise during the study recruitmentphase. Additionally, prior to completinginformed consent, patients were asked ina study information letter whether or notthey had received recommendations fromCVHCto avoid exercise. Patients whowere told not to exercise by their clinician(clinician report) and those who believedthat they were not to exercise (patientself-report) were excluded. Throughoutthe study enrollment phase, no patientswere excluded due to clinician-reportedcontraindications for exercise or studyparticipation. We considered excludingpatients without access to a DVD player,but instead decided to assess DVD accessas part of the study.

Recruitment and enrollment. Contactinformation for all patients attending clinicalvisits in the CVHC over a 3-monthtime period was collected by a clinicalstudy assistant. One to 3 weeks aftertheir initial outpatient visit, patients weresent via US mail to their home a studyinformation letter, a written consent form,

a baseline survey packet, and a postage-paid return-addressed envelope. The letterand consent form emphasized thatparticipation was strictly voluntary andwould no

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t impact their health care atMayo Clinic. Investigator contact informationwas provided for patient questionsand concerns. A total of 1781 CVHC patientswere sent study information. Ofthese, 528 (29.6%) consented to participateand returned baseline measures.Because of lack of data fromnonresponders, we are not aware of howmany self-excluded based on the perception

that exercise would be clinically contraindicatedfor them. A total of 236 participantswere randomized to interventioncondition, and 292 were randomizedto standard care. Of those randomized tothe intervention, 19 did not own DVDplayers and were sent written educationalmaterials. The data from these 19are not included in the results below. Atotal of 164 participants did not return thefollow-up measures and were sent a reminderand second copy of the measures.

Of those, one requested to discontinueparticipation, and 69 (13% of total sample)did not return the measures (48 fromintervention group and 21 from standardcaregroup). We are unaware of reasonsthat there was higher completion of follow-up measures among standard careparticipants.

Intervention. The intervention groupreceived the Mayo Clinic Section of PatientEducation DVD Exercise for Life. This DVD is 43 minutes in length andencourages use of strategies to assist inthegradual initiation and maintenanceof regular physical activity. It was createdby Mayo Clinic health care professionalsand patient education experts and incorporatesevidence-based exercise information

and behavior-change strategies.19The DVD includes basic information aboutthe benefits of exercise and encouragesuse of goal setting and other cognitive,behavioral, and motivation-enhancing

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techniques. The DVD encourages viewersto use the content to improve theirexercise program; it is not an exerciseDVD inwhich the viewer exercises alongwith an instructor. Exercise for Life isdivided into 4 modules, roughly organizedaccording to exercise stage of change.

Each module is approximately 10-12 minutesin length and can be viewed separatelydepending on the activity level andinterest of an individual. Module 1, But IHate to Exercise: The Benefits of BeingMore Active, emphasizes positive outcomesassociated with regular physicalactivity. Module 2, How Do I Get Started?Small Steps to Great Benefits, outlinessteps in the process of behavior change.Module 3, Im Ready to Exercise: MakingYour Personal Fitness Plan, describesimportant components of a well-roundedphysical activity program and how to personallytailor those to the individual. Module4, How Do I Stay With It?: FacingFailure, Overcoming Barriers and Buildingon Your Success, discusses how toface the feeling of failure in an exerciseprogra

m, how to overcome barriers andlapses, and how to enhance motivationwhen discouraged (relapse prevention).Throughout the video, commentary andimages from people who have attemptedphysical activity adoption and maintenanceare included. For example, a mandescribing his efforts to add activity duringwork is shown climbing the stairs athis workplace. Individuals of varying age,gender, ethnicity, and body size describethe personal benefits they achieved fromexercise and the strategies they used tomake and maintain change.

Along with the DVD, participants weresent a very brief letter with the followinginstructions: We strongly encourage youto watch the DVD with the goal of improvingyour current physical activity andexercise program. You may start viewingthe DVD

at the beginning, or may use theinformation on the back cover of the DVDto help you decide where to start. Participantswere not explicitly told when orhow to view the DVD. Because participantsof all activity levels were included,we did not want to specifically recommendincreasing exercise frequency. Additionallywe were interested in observinguse of the DVD, including the extentto which participants used the titles andbrief content synopses on the back coverof the DVD to stage-match content for

viewing.

Participants randomized to the controlcondition (usual care) were mailed a letterindicating that they would not receiveeducational materials during the studyperiod, but that at study conclusion (week6) they would receive the DVD.

Measures

The following measures were completedat baseline and at the end of the study(week 6). All assessments were writtenself-report measures mailed to the homesof participants. Participants who did notreturn the end-of-study assessment weresent asecond survey.

Participant characteristics. At

baseline, participants provided demographicinformation (age, gender, maritalstatus, ethnicity, employment status),reason for recent visit at CVHC (heartattack, angioplasty, heart surgery, chestp

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ain or angina, cardiovascular risk factorassessment, exercise program instructions,or annual/general exam, other),self-reported height and weight, and self-reported health using a 5-point scale frompoor to excellent.22

International Physical Activity Questionnaire-

Short.23 IPAQ-Short, is a brief7-item self-report measure of physicalactivity developed for research purposesbyinternational physical activity investigatorsas a way to standardize physicalactivity measurement. The items assessfrequencyand duration of walking, moderate-intensity activity, and vigorous-intensityactivity over the past 7 days. TheIPAQ-Short has adequate criterion validity,with IPAQ-Short reported physicalactivity significantly correlating withaccelerometry data (r = 0.34, P<0.001).24Median values and interquartile rangescan be computed separately for walking,moderate-intensity activities, vigorous-

intensity activities, and for a combinedtotal physical activity score. In this studywe used the continuous total physicalactivity score, which provides a valueinMET (ie, metabolic equivalent units, whichindicate activity intensity) minutesperweek. This MET-minutes per week valueis calculated with the following formula:Sum of walking MET-minutes per week

(3.3 x walking minutes x days) + moderateMET-minutes/week (4.0 x moderate intensityminutes x days) + vigorous METminutes/week (8.0 x vigorous intensityminutes x days).

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Stage of change for exercise. A stages-of-change-for-exercise measure25 wasused to assess readiness to exercise.This 4-item measure uses a yes/no format

and has demonstrated adequate psychometricproperties.26 Respondents werecategorized into one of 5 stages of changefor exercise based on their pattern ofresponding: (1) those not currently physicallyactive and not intending to becomemore active in the next 6 months werecategorized in precontemplation; (2) thosenot currently physically active but intendingto become more active in thenext 6 months, in contemplation; (3) thosecurrentlyphysically active, but not regularlyactive (i.e. at least 30 minutes 5 daysper week), in preparation; (4) those whowere regularly physically active, but notfor the past 6 months were in actionstage; and (5) those who had been regularlyphysically active for the past 6 monthswere in maintenance stage.

Exercise self-efficacy. A 5-item self-report measure of self-efficacy specific tophysical activity was included26 to assessconfidence to complete physical activityin different physical, emotional, and environmentalsituations (eg, when Imtired). Respondents rate their level ofconfidence to be physically active on ascale from 1 (not at all confident) to 5(extremely confident).Higher scores indicategreater self-efficacy for exercise.Scores have been found to differentiatesignificantly between individuals at differentstages of participation in exercise.

Test-retest reliability of the scale is 0.90.25Cronbach alpha for this study was 0.81 atbaseline and 0.80 at follow-up. This measurehas been used previously with medicalpatients.27

Behavioral change. A 16-item self-report measure of goal setting and relapseprevention was used to assess behavioralchange.28 Although the scale wasdeveloped for measuring behavior changewithin aphysical activity intervention,the items assess behavior in general, notspecific to physical activity. An itemfromthe goal-setting subscale is I set goals ona regular basis, and an example from therelapse-prevention subscale is Once Iam sidetracked, it is difficult for me to getback on track again. Responses rangefrom 0 (strongly disagree) to 5 (stronglyagree). The goal-setting subscale previouslyshowed adequate internal consistencyat 6 months (.74) and 1 year (.78),

and good test-retest reliability at 6 months(r=.75) and 1 year (r=.69).28 In oursample,Cronbach alpha for goal setting at baselinewas .69 and at follow-up was .71. Therelapse-prevention scale was previouslyreported to have adequate internal consistency

at 6 months (.79) and 1 year (.78)and test-retest reliability at 6 months(r=.59) and one year (r=.73).20 In oursample, Cronbach alpha for relapse prevention

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at baseline was .66 and at follow-up was .69.

Outcome expectation for exercise.Greater outcome expectations for exercisehave been associated with the adoptionand maintenance of physical activity.

The brief 9-item outcome expectationsfor exercise scale was included tomeasure physical and emotional outcomeexpectations for exercise.29 Respondentsrate their level of agreement with statementsabout the benefits of exercise (eg,makes me feel better physically andhelps me feel less tired) on a scale from1 (strongly disagree) to 5 (strongly agree).The average of all items is calculated, andhigher scores indicate more positiveoutcomeexpectations for exercise. Internalconsistency (alpha coefficient of .89), reliability(using a structural equation modeling

approach with R2 estimates), andevidence that those who exercise regularlyhave higher scores on the measurethan those who do not (F = 31.3, P<.05, etasquared = .15) have been reported.29 In ourstudy, Cronbach alpha at baseline was .89and at follow-up was .92. Outcome expectationshave also been associated withstage of change for exercise and exercisefrequency in adults.30

Usage and opinions of Exercise forLife (DVD). Items developed for this studywere used to assess the amount andfrequency of educational material use,perception of the quality of the educationalcontent, and perception of the impact

of the DVD.

Statistical Analyses

Baseline. Descriptive statistics, includingfrequency and percentage for categoricalvariables, and mean, standarddeviation, median, and range for continuousvariables, were used to summarizeparticipant characteristics. Baselinegroup differences were assessed withPearsonschi-square test for categoricalvariables and the Kruskal-Wallis test forcontinuous variables.

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Group comparisons at follow-up.Exercise frequency and the cognitive behavioralvariables previously associatedwith increased exercise frequency (allcontinuousscores) were analyzed withindividual linear regression models. Ineach model, the

dependent variable is thechange in score from baseline (week 6minus baseline),and the predictors arethe baseline score, treatment group (DVDvs standard care),and a baseline by treatmentgroup interaction. One model wasestimated for each score. These modelsestimate the effect of treatment group onscore changes adjusted for the baselinescore. In essence, these models fit separateregression lines for change in scorevs baseline score (one for each treatmentgroup) and allow for assessing whetherthe relationship changes depending onwhich treatment a patient received. Testsof significance for slopes were calculatedusingthe estimated coefficients, standarderrors, and coefficient covariances.If the interaction term was not significant,

it was removed from the model forinterpretation of the treatment effect.Participants assigned to the DVD conditionwho reported that they did not watchthe DVD were retained in the analyses.

Stage of change for exercise at follow-up. Progression in stage-of-changedifferences (backward progression vs staythe same vs forward progression; week 6relative to baseline) were compared betweentreatment groups using a stratifiedCochran-Mantel-Haenszel meanscore test, controlling for the baselinestage of change. This test measures theassociation between treatment group andstage-of-change difference at each levelofthe baseline stage of change and thenpools these associations across thebaselin

e levels to get an overall test.Subsequent mean score tests were computedfor each baseline level.

Usage and opinion of DVD. Descriptivestatistics (percentage, mean, standarddeviation) were used to summarizeintervention group responses to theseitems developed for this study.

RESULTS

Participant Characteristics

Participant characteristics for the entiresample and also for the interventionand control group separately are shown inTable 1.

The majority of participants were white,

male, older adults with a college-leveleducational background. There were nodifferences between intervention groupand control group participants at baseline.Participants self-reported the followingreasons for their recent cardiovascularhealth visit (they could indicate all thatapply): cardiovascular risk factor assessment(40%), chest pain or angina (23%),

annual/general exam (21%), other (18%;wide range of responses, most related tohistory of symptoms/event or concernabout risk factors), recent angioplasty(9%), for exercise recommendations (8%),

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recent heart surgery (7%). The averageBMI calculated from self-reported weightand height fell into the overweight (BMI of25 29.9), but not obese (BMI of 30 orgreater) category.31

Baseline Physical Activity Frequency

There was no difference between groupsat baseline for total physical activity (m

edianMET minutes per week). Both groupswere physically active at baseline (medianMET min/week = 1794 for interventionand 2034 for control). When calculatedas minutes per week (without metabolicequivalent units), the mean (SD)minutes for the entire sample at baselinewas 569 (534) minutes per week, or approximately81 minutes of physical activityper day.

Cognitive Behavioral Variables at

Baseline

The majority (70%) of participants werecategorized in either the action or maintenancestage of change at baseline (13%action; 57% maintenance), with no significantdifference between groups.Groups did not differ on baseline exerciseself-efficacy, goal setting, relapse prevention,or outcome expectations for exercise.

There was no significant impact ofintervention group on change frombaseline in physical activity frequency atfollow-up, as is shown in Table 2.

Cognitive Behavioral Variables at

Follow-up

Table 2 presents group comparisons forthe cognitive behavioral variables. At follow-up, participants sent the DVD reporteda significantly greater increasefrom baseline in positive outcome expectations(perceived personal benefits ofexercise) than did those in standard care

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Table 1Participant Characteristics, Exercise Frequency, and CognitiveBehavioral Variables at Baseline

Overall DVD Group Control Group Test P-Summary Summary Summary Statistica valuea

(N=509) (n=217) (n=292)Variable n (%) n (%) n (%)

Gender

Male 351 (69%) 148 (68%) 203 (70%) 0.10 0.751Female 158 (31%) 69 (32%) 89 (30%)

Self-reported Health

Excellent 61 (12%) 27 (13%) 34 (12%) 6.57 0.160Very Good 208 (42%) 88 (41%) 120 (42%)Good 177 (35%) 67 (31%) 110 (38%)Fair 50 (10%) 29 (14%) 21 (7%)Poor 5 (1%) 2 (1%) 3 (1%)

Marital Status

Married 421 (83%) 179 (83%) 242 (83%) 0.01 0.911

Other 86 (17%) 36 (17%) 50 (17%)

Race/Ethnicity

White 487 (96%) 205 (95%) 282 (97%) 0.49 0.483Other 20 (4%) 10 (5%) 10 (3%)

Employment

Full-time 234 (46%) 101 (47%) 133 (46%) 0.91 0.823Part-time 39 (8%) 15 (7%) 24 (8%)Retired 189 (37%) 78 (36%) 111 (38%)Other 44 (9%) 21 (10%) 23 (8%)

Stage of Change

Precontemplation 12 (2%) 2 (1%) 10 (4%) 7.00 0.136Contemplation 12 (2%) 4 (2%) 8 (3%)Preparation 119 (24%) 48 (23%) 71 (25%)Action 66 (13%) 35 (17%) 31 (11%)Maintenance 282 (57%) 117 (57%) 165 (58%)

Mean (SD) Mean (SD) Mean (SD)

Median Median Median(min, max) (min, max) (min, max)

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Age (years)61.2 (12.8) 61.4 (12.2) 61.1 (13.2) 0.002 0.96162 (28, 97) 60 (30, 91) 62 (28, 97)

BMI (from self-reported 28.0 (4.5) 27.6 (4.4) 28.2 (4.6) 2.07 0.150height and weight) 27.4 (16.4, 45.3) 27.1 (16.4, 41.5) 27.9 (17.8, 45.3)

Years of Education16.5 (3.6) 16.5 (3.5) 16.5 (3.7) 0.13 0.72216 (8, 23) 16 (8, 23) 16 (9, 23)

IPAQ Total Score 2690.2 (2580.9) 2631.4 (732.2) 2736.1 (2462.1) 1.11 0.292(MET min/week) 1918 (0, 15120) 1793.5 (0, 15120) 2034 (0, 12852)

Exercise Self-efficacy3.3 (0.8) 3.2 (0.9) 3.3 (0.8) 0.49 0.485

3.4 (1, 5) 3.2 (1, 5) 3.4 (1, 5)Goal Setting 20.5 (3.5) 20.2 (3.4) 20.7 (3.6) 2.38 0.123

21 (10, 29) 20 (10, 29) 21 (11, 29)

Relapse Prevention 20.7 (3.4) 20.8 (3.5) 20.6 (3.4) 0.07 0.79221 (10, 30) 21 (10, 30) 21 (11, 27)

Outcome Expectations4.1 (0.5) 4.1 (0.5) 4.2 (0.5) 1.34 0.2484 (2.6, 5) 4 (2.6, 5) 4 (2.6, 5)

Notes.a Pearsons chi-square test was used for categorical variables, and Kruskal-Wallistest was used for continuous variables.

(P=0.01). A significant interaction wasprevention behavior at baseline (25th per-found between relapse prevention and

centile = 19) were significantly more likelyintervention group: those low on relapse-

to increase this behavior by follow-up if

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Table 2Group Comparisons for Exercise Frequency and CognitiveBehavioral Variables at Follow-up

Outcome Parameter t-P(week 6 baseline) Variable Estimate (SE) statistic value N R2

IPAQ TotalIntercept 1172.1 (244.7) 4.79 <0.001 262 0.09

(MET min/wk)Baseline IPAQ total -0.31 (0.06) -5.06 <0.001

DVD vs. control 218.0 (298.5) 0.73 0.466

Exercise Self-Intercept 1.05 (0.13) 8.11 <0.001 430 0.19efficacy Baseline self-efficacy -0.36 (0.04) -9.67 <0.001DVD vs. control 0.12 (0.06) 1.85 0.066

Goal SettingIntercept 6.07 (0.74) 8.17 <0.001 427 0.15Baseline goal setting -0.30 (0.04) -8.61 <0.001DVD vs. control -0.03 (0.26) -0.10 0.919

Relapse Prevention Intercept 5.10 (1.01) 5.04 <0.001 428 0.18Baseline relapse -0.26 (0.05) -5.43 <0.001prevention

DVD vs. control 4.61 (1.60) 2.87 0.004Interactiona -0.20 (0.08) -2.70 0.007

Outcome Expectations Intercept 1.28 (0.18) 7.27 <0.001 409 0.14Baseline outcome -0.32 (0.04) -7.76 <0.001expectationsDVD vs. control 0.12 (0.05) 2.53 0.012

Notes.a Interaction term is group (DVD vs control) x baseline score

they were in the intervention group ratherthan standard care (DVD vs standard caredifference = 0.71, P=0.02). There was nosignificant impact of intervention groupon change from baseline in exercise self-efficacy or goal-setting behavior. At follow-up, a significant Cochran-Mantel-Haenszel mean score test (value = 6.01;P=0.01) indicated a significant associationbetween treatment group and stageof-change difference for at least one levelof the baseline stage of change. Subsequentmean score tests for each baselinestage-of-change level revealed a significantassociation between treatment groupand stage-of-change difference for thebaselin

e for action and maintenancestages of change. More participants inthe control group than in the intervention

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group (46% vs 11%; test value = 5.64,P=0.02) progressed from action stage atbaseline to maintenance stage at follow-

up, and more intervention group participants(18%) moved backward from maintenancestage at baseline than did controlgroup participants (8%) at follow-up(test value = 5.47, P=0.02). There were no

significant associations between treatmentgroup and stage progression at follow-up for those at precontemplation, contemplation,or preparation stages atbaseline. There were significant missingdata in the stage-of-change analysis (18%of data missing).

Usage and Opinions of DVD Among

Intervention Group

Table 3 summarizes data from items

written for this study to assess the DVD.Of those participants assigned to intervention,most watched the DVD one timefrom beginning to end. The content of theDVD was not new to most, but quality andsatisfaction with the DVD were rated fairly

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Table 3Intervention Group Usage and Opinions of DVD

Survey Itemn (%) Mean (SD)

Did you watch any of the DVD?

No, none 35 (21%)Yes, some of the DVD 18 (11%)Yes, I watched all of the DVD 111 (68%)

Did you watch any part of the DVD more than one time?

No 122 (78%)Yes 35 (22%)

The DVD was presented in 4 chapters to match different levels ofexperience with and motivation for exercise. Did you pay attentionto the information on the back of the DVD about chapter contentwhen watching the DVD? a

Yes, I matched the chapter to my experience/motivation 17 (22%)No, I watched it from beginning to end 50 (64%)I dont remember/other 11 (14%)

When you watched the DVD, did you watch it all at once in onesitting or sections of it at different times? a

All at once, in one sitting 51 (65%)At different times 20 (26%)I dont remember/other 7 (9%)

How much of the information and content in the DVD was new to you?

(1= none; 9 = quite a bit)3.15 (1.76)

How would you rate the quality of the content within the DVD?

(1=poor quality; 9 = excellent quality)6.99 (2.07)

How would you rate your overall satisfaction with the DVD?

(1=not at all satisfied; 9 = extremely satisfied)6.61 (2.15)

To what extent did the DVD impact your attitude about exercise?

(1= not at all; 9 = quite a bit)5.28 (2.62)

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To what extent did the DVD impact your exercise frequency or intensity?

(1= not at all; 9 = quite a bit)4.41 (2.58)

Notes.

aThese 2 items were added midway through the study to clarify use of DVD, thus the smallernumber of responses

high. Participants reported some modestimpact of the DVD on attitude about exercise.

CONCLUSION

The exercise-education DVD interventiondid not significantly increase physicalactivity frequency at 6-week follow-up, as compared to standard care. The

relatively high exercise frequency amongparticipants in this sample at baselinelikely impacted results, as many reportedactivity frequency already meeting orexceeding the public health guidelines.32As a comparison, the IPAQ-Short medianMET minutes per week at baseline forsedentary adults enrolled in an exerciseintervention was 480 MET minutes/week

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for the intervention group and 524 METminutes/week for the control group.33Median MET minute/week at baselinefor our sample was 1794 (intervention)and 2034 (control). As patients of theCardiovascular Health Clinic, participantshad received specific recommendationsto exercise, and for returning patients,

this information could have been repeatednumerous times. Further, because mostof the patients seen in this clinic havesome cardiovascular disease risk factors or history of cardiac event, this group maybe particularly motivated toward exercise.Because the educational DVD usedin this study was not developed specificallyfor any patient group, it could beassessed within samples of patients whoseactivity level closer approximates the generalpublic, such as in a primary caresetting.

Participants in the intervention groupincreased their positive expectationsabout

exercise, which is an importantmediator of physical activity adoption.20Because video media are particularlysuccessful in modeling health behaviors,it is likely that the content and delivery ofthe physical activity information wereimportant in increasing positive expectations.After one has viewed other peoplewho may share similar barriers to exercisebut who have overcome those barriersand achieved benefits, cognitionsabout exercise can change. Additionally,those who reported less relapse-preventionbehavior at baseline reported morerelapse-prevention behavior after receivingthe DVD. Because the majority ofparticipants were already in maintenancestage ofchange for exercise at baseline,relapse-prevention skills that can assistwith getting back on track after a lapse(such as a period of inactivity during anillness) may be particularly important

forthis patient group. Consequently, thevideo content addressing relapse preventionmay be most relevant to the alreadyphysically active. Future research shouldassess the impact of the intervention onrelapse prevention over time. Althoughfewerintervention than control participantsprogressed from action to maintenancestage of change (ie, reported theywere regularly physically active atbaseline, reported being regularly physicallyactive for the past 6 months at follow-up), it is not clear how intervention orcontrol group assignment would impact

amount of time a person has been regularlyphysically active, when already regularlyactive at baseline. High levels ofbaseline activity may also explain lack ofgroup differences on exercise self-efficacy.

The majority of participants who receiveda DVD reported watching the DVD,however not in the manner we expected.Because the DVD was presented in chaptersthat roughly matched stages of readinessto initiate physical activity,19 participantshad the opportunity to go directlyto the content that best reflectedtheir current experience and attitudesabout ex

ercise. However, most reportedwatching the DVD from beginning to end,one time through, at a single sitting;much as one would watch a movie for

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entertainment. This information is importantwhen considering how to orderand deliver information in a physical educationvideo to engage viewers at varyingactivity levels.

Several limitations in the current studyare relevant when considering next stepsfor video-delivered physical activity interventions.Although the IPAQ-Short hasbeen validated with performance measures

(accelerometer data), use of a moreobjective measurement of exercise frequencysuch as wearable device or structuredphysical activity interview is typicallypreferred over self-report due to thepotential for overreporting activity on self-report measures.34 To advance the scienceof physical activity intervention research,studies should include longertime to follow up than the 6 weeks in thisstudy toassess for any long-term maintenanceof intervention effects. We enrolledapproximately 30% of likely-eligibleparticipants, and 13% of participants didnotcomplete the study (more in the intervention

group). Nonresponders are likelydifferent from those who completed thestudy, limiting our ability to generalizeour findings. We are unaware of reasonsthat morecontrol group participants completedthe study than intervention groupparticipants, but speculate that the standardcare group might have had lowerexpectations for a change in exercisethan the intervention group just by natureof group assignment. Consequently,those in the intervention group who didnot view the video or did not improve theirexercise program may have preferred notto report that information. The DVD us

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Vickers et al

age and opinion survey items were developedfor this study and not previouslyvalidated. Finally, because we enrolledparticipants at all levels of baseline activity(including those who are frequentlyactive), we did not provide specific instruct

ionto increase exercise frequency.Consequently, we do not know the impactof brief recommendations to increaseexercise frequency along with the DVD.

Future research with video-deliveredphysical activity education should considertesting the intervention on patientgroups most likely to benefit from thecontentand assess the impact of adjunctiveintervention strategies. Previousphysical activity interventions testingnon-face-to-face delivered content (printmaterials and tailored telephone-deliveredmessages) included only initiallysedentary individuals.7,10 Because the

exercise education DVD in this studysignificantly increased outcome expectations for exercise in an already activepatient group, it would be worthwhile totest whether the DVD would similarlyimpact cognitive behavioral variables andeven increase exercise frequency amonga sample of sedentary individuals. In additionto the sedentary, there may beother subgroups of cardiovascular healthclinic patients who could benefit fromthis type of intervention. Depression is acommon comorbidity among patients withcardiovascular disease.35 Because patientswith chronic conditions can experienceemotional and cognitive behavioralbarriers to exercise,36,37 interventionsthat offer encouragement and cognitiveand behavioral strategies to address thesebarriers are important. Future researchwith video-delivered physical activity co

ntentshould also assess minimal adjunctiveintervention components that couldboost the effectiveness of the intervention.Because modeling of attitudes andbehavior can be accomplished in videomedia, modeling could be extended toinclude patients demonstrating an exerciseroutine, allowing the viewer to exercisealong with the video content. A recentstudy38 assessed the impact of amotivational exercise DVD (benefits ofexercise)and an exercise demonstrationDVD (exercise routine appropriate for patientswith chronic obstructive pulmonarydisease, designed so patients canexercise along with the video) for patientswithCOPD. The group receiving the exer

cise DVDs demonstrated improved fitnessand less breathlessness than did acontrol condition. Other minimal interventionssuch as brief (3-to-10-minute)clinician-delivered recommendations forexercise and written prescriptions forexercise, which have been shown to increasephysical activity,1 could be pairedwith the DVD to potentially enhance interventioneffects.

The results of our study suggest thatthis very minimal intervention is feasiblein a clinical setting. Beyond theinitial production costs of the video, dissemination

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of the video was low cost andrequired no clinical contact time. Thevideo positively impacted cognitive behavioralvariables associated with exercise,but did not increase exercise frequencyin this relatively active sample.Further research is needed to identifysubgroups of patients who might benefitmos

t from a video-delivered physical activityintervention and the additional interventioncomponents that could maximallyhelp patients initiate and maintainregular physical activity.

Acknowledgment

The authors wish to thank JulieHathaway and Debra Judy in the MayoClinic Section of Patient Education fortheir invaluable assistance with data collectionand manuscript preparation. Theefforts of the DVD production team, includingRita Jones, Margaret Harmon,

Lonnie Fynskov, Tammy Adams, TomWilliams, Richard Busey and other contributingpatient education and clinicianexperts are sincerely appreciated. Weare also truly grateful to all patient participants.

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