The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7213.828 (Published 25 September 1999) Cite this as: BMJ 1999;319:828All rapid responses
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We welcome the article on promoting physical activity in primary care
(1) and the responses to this article to date. We agree with the authors
that few of the schemes being implemented in general practice have been
rigorously evaluated. However, we also agree with several of the responses
to this article, that the authors' conclusion 'that these schemes are of
questionable effectiveness' is premature and that the banner comment,
'Exercise on prescription is a waste of scarce resources' in the same
issue is misleading and not justified by evidence to date.
Our response stems from concerns about their intervention approach
and our experience in two research endeavours; implementing a physical
activity prescription scheme in New Zealand, and a recently published
randomised controlled trial resulting in long term improvement in physical
activity for older people (2).
Firstly, we question whether the level of intervention with the
control group (i.e. giving them information on the benefits of physical
activity, recommended activity levels and leaflets on leisure facilities
and activities available locally), results in a "true" control. As the
control group had a significant improvement in physical activity also, the
comparison may have been with a lesser intervention, rather than a true
control group.
Secondly, we question whether lengthy motivational interviewing is an
appropriate intervention and replicable in a general practice setting. It
was not clear from the article whom exactly undertook the counselling.
This approach is time-intensive for GPs and limits effective long-term
follow-up. It is also questionable whether it is feasible for practice
nurses to sustain such a programme. In New Zealand, where 51% of GPs are
now prescribing physical activity through the Hillary Commission's Green
Prescription scheme (3), one of the major barriers general practitioners
give for not prescribing physical activity is lack of time during the
consultation (4,5). We contend that interventions that are quick and
simple to implement offer more potential for sustainability and long-term
effectiveness.
A recent RCT, set in Melbourne Australia, showed physical activity
increases sustained for at least 12 months (2). The successful approach
taken in Melbourne was to raise the consciousness of the GP about the
importance of physical activity through an effective educational
programme, but leave the details of whom to target and the exact content
of advice given, to the professional judgement of the GP. This contrasts
to the Newcastle programme where the GP appeared a virtual bystander to
the intervention design and delivery. This raises the overall question as
to whether interventions where the judgement of the GP is key may be more
effective than strictly defined intervention packages aimed to be merely
'delivered' by the GP. It is clear that individualised assessment and
program design benefit outcome in health promotion trials. We contend that
the GP should play a stronger role in this area in future physical
activity interventions.
We recognise the need for outcome-based evaluations in this area of
health promotion. A three-year study (funded by the National Heart
Foundation, NZ Ministry of Health and the Hillary Commission) has just
begun in New Zealand. This will evaluate the long-term effectiveness of
Green Prescriptions in improving health outcomes of middle-aged and older
people at risk from physical inactivity, comparing the intervention to a
true control group, receiving no advice. Effectiveness will be measured by
changes in cardiovascular risk index, and quality of life and health
status assessments.
It is hoped that information from our NZ study will add value and
validity to the body of knowledge acumulating as to the effectivenes of
primary care physical activity intervention.
Ngaire Kerse, FRNZCGP, PhD, Senior Lecturer, Department of General
Practice and Primary Health Care, University of Auckland
Sue Walker, PhD, Research and Information Manager, Hillary Commission
for Sport Fitness and Leisure
References
1. "The Newcastle exercise project: a randomised controlled trial of
methods to promote physical activity in primary care" Jane Harland, Martin
White, Chris Drinkwater, David Chinn, Lorna Farr, and Denise Howel. BMJ
1999; 319: 828-832
2. "Improving health behaviours of the elderly: a randomised
controlled trial of a general practice educational intervention" NM.
Kerse, D Jolley, B Arroll, L. Flicker, D Young. British Medical Journal
1999;319:683-7
3. IMS Health (NZ) Ltd. Green Prescriptions in General Practice.
Summary Report, November 1999.
4. Swinburn BA, Walter LG, Arroll B, Tilyard MW, and Russell DG.
Green prescriptions: attitudes and perceptions of general practitioners
towards prescribing exercise. Br J of Gen Pract, 1997;47:567-9.
5. Swinburn BA, Walter LG, Arroll B, Tilyard MW, and Russell DG. The
Green Prescription Study: A randomized controlled trial of written
exercise advice provided by general practioners. Am J Public Health,
1998;88:288-291.
Competing interests: No competing interests
Editor – Harland et al. have made a valuable contribution to the
evidence base that currently underpins the promotion of physical activity
(1). Whilst welcoming their contribution, we are concerned that several
features of their study may reduce the external and internal validity of
the conclusions that have been reached.
The study described does not examine an exercise on prescription
scheme. All patients aged 40-64 attending surgeries were approached and
considered. This is, therefore, a population sample, not a targeting of
selected patients by a general practitioner. Furthermore, because the
response to this initial invitation to participate was low, those who
agreed to participate may have been the most enthusiastic, and not
representative of the general population. This may have reduced both the
likelihood of proving the effectiveness of the intervention and the
validity of the findings with respect to the general population.
The interventions that were evaluated were very intensive and are
unlikely to be feasible in an average primary care setting. In addition,
whilst the specific method of promoting physical activity is undoubtedly
an important issue, it does not stand alone. It is also necessary to
consider broader social factors that may mask the effect of an
intervention at this level. These would include the availability of time
to attend, and accessibility of, facilities.
The authors have based sample size calculations on the number of
participants that would be required to detect a difference between success
rates of 40% - 60%. In addition to the fact that the required number of
participants was not met, the prospect of achieving such a large
difference in success rates seems rather ambitious.
Although we agree with the authors’ conclusion that further research
is necessary to develop interventions that promote long-term adherence to
exercise, it is important that the exercise on prescription scheme is
differentiated from population strategies that attempt to raise the level
of exercise generally.
Marko Petrovic
Specialist Registrar in Public Health Medicine
North Wales Health Authority
Jeremy Corson
Deputy Director of Public Health
North Wales Health Authority
Hilary Fielder
Clinical Senior Lecturer Public Health Medicine
University of Wales College of Medicine
Lyndon Miles
Specialist Registrar in Public Health Medicine
North Wales Health Authority
Elwyn Williams
Health Promotion Manager
North Wales Health Authority
Health Promotion Unit, Mold
1. Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The
Newcastle exercise project: a randomised controlled trial of methods to
promote physical activity in primary care. BMJ 1999; 319: 828-32.
Competing interests: No competing interests
EDITOR --- I applaud Harland et al for attempting to appraise the
efficacy of GP exercise prescription. However the programme that they
studied in Newcastle is unlikely to be achieve long-term changes in life
style because it is vitally flawed. To achieve compliance participants
need to go through their exercise programme in mutually supportive groups.
A scheme in Mid-Devon in which participants felt part of a group of
about 15 has been extremely popular and successful. In 1994 a health
script scheme was started in Cullompton, a market town in Devon pop.
6,000. 33 General Practitioners (GPs) with a total of 47,855 patients on
their lists were
invited to participate in the scheme, and 474 patients were referred to
the Culm Valley Sports Centre over a 12 month period 1995-6 for the
following reasons in rank order: generally unfit, overweight,
depression/fatigue, back
pain, post heart surgery, post injury, arthritis/immobile, hypertension,
neurological problems, diabetes. The programme was set up with the help of
a local physiotherapist who worked with an exercise trainer who was
dedicated full-time to the scheme. A study of chronic back pain was
carried out looking at pain on visual analogue scale (VAS), Oswestry
disability score and hospital anxiety and depression score (HAD), and all
these parameters were seen to improve after 12 weeks in the exercise
scheme. There was very little fall out and 80% were attending the sports
centre a year later.
Funds for additional equipment were provided by the Mid-Devon
District Council. Participants paid reduced charges (£1-95 instead of £2-
60) and in groups of about 10 attended twice a week for 10 weeks at off
peak times.
They had a free initial assessment (normally £9) which included BP, pulse
rate before and after exercise, body dimensions, fat thickness, peak flow
recording. Despite the reduction in charges the scheme has been self-
funding.
Fox et al.(1997) have studied exercise prescription schemes and they
included amongst the advantages:
o ease with which GPs can contribute
o willingness of leisure centre to take on responsibility
o availability of expertise and facilities
o popularity amongst patients
o motivational effect of group exercise
o financial viability.
The Mid-Devon scheme corroborates these. It was found that carefully
selected patients usually do well, have fun, and report benefits to their
physical and psychological well-being. There is no delay in starting the
programme and this can be a benefit when deconditioning is taking place.
There may be positive advantages in removing people from the medical
arena.
I suggest that the type of exercise programme is vital to the success
of an exercise prescription scheme, and that long term changes in exercise
behaviour may result from participants attending in cohesive groups.
Peter JS Baker MB,BCh,BAO;DCH;DRCOG;DOccMed
Denmark Road,
Exeter
EX1 1SE
Competing interests: No competing interests
Editor..We would like to take issue with your banner comment,
'Exercise on prescription is a waste of scarce resources' on Harland et
al's physical activity article in the 25/9/99 issue . The article showed
that all four intervention groups showed a significant increase in self-
reported activity at 12 weeks, compared to a control group that itself
increased reported activity in 16%. In addition there was a suggestion of
a dose response effect as the greatest increase was seen in the group with
financial inducement and multiple interventions. It was a pity that they
did not report in this article on the physiological and exercise test
outcomes.
As the authors note, the control group had in effect a brief intervention
akin to an exercise prevention. This trial produced no evidence that more
intense intervention in the short term produces sustained effects, as
reflected by the findings at one year. This is not surprising given the
trial design. Numerous other studies , , show that frequent contact with
the subjects, even by brief telephone calls limit drop outs, and that
perhaps at least six months of profession contact is needed before the
increased physical activity pattern becomes incorporated into behaviour.
The key seems to be not so much intensity of contact, rather continuity
over time. Such continuity is a feature of general practice: this should
remain an arena for testing such interventions.
Harland's trial shows that in UK general practice patients may be
recruited from a relatively deprived inner city area, and their physical
behaviour can be increased by intervention from a researcher, mirroring
encouraging trials with primary care physicians from the USA & NZ , .
What they haven't shown is how to maintain the increased activity. This
requires further studies, and we believe your banner headline is
misleading and discouraging to researchers and funding authorities.
Frank Smith
Director of Postgraduate GP Education
NHS Executive,
Wessex Deanery,
Highcroft,
Winchester SO22 5DH
Jane Sims
Senior Lecturer
Dept General Practice & Public Health,
University of Melbourne,
Australia
1. Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The
Newcastle exercise project: a randomised controlled trial of methods to
promote physical activity in primary care. BMJ 1999;319:828-32.
2. Murdo ME, Burnett L. Randomised controlled trial of exercise in
the elderly. Gerontol 1992;36:292-8.
3. Hamdorf PA, Withers RT, Penhall RK, Plummer JL. A follow up study
on the effects of training on the fitness and habitual activity patterns
of 60-70 year old women. Arch Phys Med Rehab 1993;74:473-7.
4. King A, Haskell W, Taylor C, Kraemer H, DeBusk R. Group- vs home
based exercise training in healthy older men and women. A community based
clinical trial. JAMA 1991;266:1535-42.
5. Swinburn BA, Walter LG, Arroll B, Tilyard MW, Russell DG. The
green prescription study: a randomised controlled trial of written
exercise advice by general practitioners. Am J Public Health 1998;88:288-
91.
6. Calfas KJ, Long BJ, Sallis JF, Wooten WJ, Pratt M, Patrick K. A
controlled trial of physician counselling to promote the adoption of
physical activity. Preventive Medicine 1996;25:225-33.
Competing interests: No competing interests
We welcome the addition of this study to the debate on the efficacy
of exercise referral. However, we believe that Harland et al 1 have asked
the wrong questions and therefore have drawn the wrong conclusions.
The first flaw in their questions was to ask whether there was a
difference between the various interventions and control in changes in
physical activity score from 12 weeks to one year. Since there were no
differences, the today in the BMJ headline states that ‘exercise
prescription is a waste of scarce resources’. A better question would be
to ask whether any group had increased their activity at one year
compared to baseline. According to the data the authors present in Table 2
(page 831), the percentage of participants who had increased physical
activity scores at one year compared to baseline, ranged from 23% in
control group to 31% in Intervention 3. If these are significant changes
from baseline then the conclusion might have been that even the control
condition can have a substantial impact in increasing physical activity
over one year. Further economic analysis might then determine that the
control (which seems to include the basis of many intervention techniques
such as assessment, feedback and the provision of information) was the
most cost-effective intervention. The authors’ conclusion that brief
interventions are of questionable effectiveness is wrong since none of
their interventions or even the control condition could be described as
brief. In our own research we have shown that much briefer interventions
(only the provision of an information booklet) can still increase physical
activity up to six months2.
Another flaw in the line questioning was to base the outcome measures
on an outdated questionnaire which has no substantial validation. A better
option would have been to use the current ‘Active Living’ message3 and to
measure total physical activity via a validated recall4. This flaw means
that it is hard to determine if participants have achieved the current
targets5 for sedentary individuals of accumulating 30 minutes of moderate
activity on most days of the week.
The authors claim that the research is based on the stage of change
model. However, they have not reported how interventions were tailored to
stages, any details of pre or post intervention stages, effectiveness of
interventions by stage, or of the other crucial elements of this model
such as the processes of change and self-efficacy measures6. If these
aspects of the stage of change model had been incorporated there would be
more information available for future researchers and practitioners and
perhaps different conclusions.
These flaws mean that the key messages are very misleading and that
the conclusions drawn are not evidence based. Such misinterpretation
could severely limit future research and service developments. Given
that government targets 5 for increasing physical activity have just been
set, such limitations would be premature and unjust.
References
1. Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The
Newcastle exercise project: a randomised controlled trial of methods to
promote physical activity in primary care. BMJ 1999; 319: 828-32.
2. Loughlan, C. & Mutrie, N. An evaluation of the effectiveness of
three interventions in promoting physical activity in a sedentary
population. Health Education Journal 1997; 56:154-165.
3. Pate RR., Pratt M., Blair SN., Haskell WL., Macera CA., Bouchard C et
al., Physical activity and public health: a recommendation from the
Centres for Disease Control and Prevention and the American College of
Sports Medicine. JAMA 1995; 273 (5):402-407.
4. Lowther, M & Mutrie, N. Development of a Scottish physical activity
questionnaire: a tool for use in physical activity interventions. Br J Sp
Med 1999; 33: 1-6.
5. The Scottish Office. Towards a healthier Scotland - a white paper on
health. Edinburgh: The Stationary Office. 1999.
6. Marcus BH, Eaton, CA Rossi JS, Harlow LL. Self- efficacy, decision-
making, and stages of change: an integrative model of physical exercise.
Journal of Applied Social Psychology 1994; 24:489-508.
Nanette Mutrie,
Catherine Woods,
Mathew Lowther,
Centre for Exercise
Science and Medicine, University of Glasgow
Avril Blamey,
Greater Glasgow
Health Board
Chris Loughlan,
Research and Development, Addenbrookes
Hospital, Cambridge
Competing interests: No competing interests
Harland et al. (1) have questioned the effectiveness of 'exercise on
prescription' schemes, based on the findings of a randomised controlled
trial that assessed two levels (brief and intensive) of motivational
interviewing and financial incentives, as adjuncts to knowledge of test
results, activity information, advice, and leaflets. We welcome their
findings as a contribution to the scarce literature on effectiveness, but
question the validity of their conclusions, on two grounds.
First, we feel that the results of the trial are extremely positive.
We fail to see why a rather negative conclusion has been reached when the
null hypothesis was rejected and the effect of the intervention to promote
adoption of activity (the stated aim of the study) was strong. Forty
percent of intervention and 23% of control participants improved activity
status within a population that is notoriously difficult to influence.
This level of success is far greater than other behaviourally focussed
trials of physical activity, smoking or weight loss. It is misleading to
dwell on the more disappointing long term adherence, as such effects can
only be achieved by long-term intervention strategies, which were not
evident in this trial.
Second, the Newcastle trial is far from reflective of the great
majority of UK schemes. Most existing schemes are leisure centre, rather
than primary care, based and involve physical activity specialists working
with clearly targeted groups. Social group settings and class activities
are frequently used, and activity programmes are tailored to the health
needs of the individual. In contrast, the Newcastle trial uses broad-based
recruitment and a single health visitor to deliver motivational
interviewing and financial incentives. The popular model, which has been
clearly outlined (2,3), has therefore not been tested by this trial.
We feel, therefore, that the authors' statement "brief interventions
promoting physical activity that are used by many schemes in the United
Kingdom are of questionable effectiveness", is not substantiated from the
results of their study. Although this is a well-designed study, we feel
that a more appropriate conclusion would be that this combination of
intervention elements has achieved positive, graded effects, and this can
inform the design and increase the effectiveness of other schemes. We fear
there is a serious danger of prematurely fuelling the armory of the
physical activity "sceptics" and unfairly setting back genuine attempts to
find successful ways of promoting physical activity from the primary care
base.
References
1. Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The
Newcastle exercise project: a randomised controlled trial of methods to
promote physical activity in primary care. BMJ 1999;319:828-32.
2. Fox K, Biddle S, Edmunds L, Bowler I, Killoran A. Physical activity
promotion through primary health care in England. Br J Gen Prac
1997;47:367-9.
3. Riddoch CJ, Puig-Ribera A, Cooper A. Effectiveness of physical activity
promotion schemes in primary care: a review. London: Health Education
Authority, 1998.
Chris Riddoch: Senior Lecturer, Exercise and Health Science
Jim McKenna: Lecturer, Exercise and Health Science
Ken Fox: Professor, Exercise and Health Science
Department of Exercise and Health Sciences, University of Bristol, 8
Woodland Road, Bristol, BS8 1TN.
e-mail: chris.riddoch@bristol.ac.uk
Competing interests: No competing interests
Dear Editor
The paper by Harland et al describing the Newcastle exercise project1
concludes that "brief interventions promoting physical activity that are
used by many schemes in the United Kingdom are of questionable
effectiveness". The data presented do not support this gloomy assertion,
and the bold heading on the "This Week" page in the same edition of the
BMJ which states that "exercise on prescription is a waste of scarce
resources" is totally unjustified and seriously misleading.
Notwithstanding previous pessimistic views on the subject2, there is
nevertheless evidence to suggest that general practice-based physical
activity interventions may be both beneficial for public health gain3,4
and cost effective5.
The recent Newcastle study sets out to see what effects various
interventions have on increasing and maintaining activity levels in a GP
population1. These are shown to be better than "control" at 12 weeks but
no better at one year. However, the "control" group in fact received a
considerable intervention, which consisted of an initial assessment (75
minutes of structured interview, physical measurements and a cycle
ergometer test), and a follow up interview in which they received their
baseline results (blood pressure, weight for height, activity level and
aerobic capacity, smoking and alcohol consumption), and a pack containing
information on the benefits of physical activity, other lifestyle factors,
recommended activity levels, 19 leaflets on local leisure facilities, and
brief advice comparing the individual's results with recommended levels.
It might be that the "control" intervention (which superficially looks as
though it is just a data collection exercise) is in itself a powerful
motivation for change. A valid control group which received no
intervention would have had just the baseline activity data collected,
without the physical measurements, the cycle ergometer test and the follow
up interview. That way a true baseline of "spontaneous converters" to
increased activity levels amongst the study population could have been
estimated, and the size of the "control intervention" effect could have
been calculated.
What the results show is that 23% of the "control intervention" group
had an increase in their physical activity score at one year, which is an
impressive improvement. If it could be repeated across the population as
a whole the health benefits would be considerable. The fact that the
extra interventions did not add any value to the "control" at one year is,
on the one hand disappointing, but on the other suggests that the
resources used to provide these extra interventions would be better spent
on giving more people the "control" intervention instead.
Yours faithfully
Dr Stephen Longworth
Dr John A White
1 Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The
Newcastle exercise project: a randomised controlled trial of methods to
promote physical activity in primary care. BMJ 1999; 319: 828-32.
2 Iliffe S, See Tai S, Gould M, Thorogood M. Prescribing exercise in
general practice - look before you leap. BMJ 1994; 309: 494-495.
3 McKenna J, Naylor P-J, McDowell N. Barriers to physical activity
promotion by general practitioners and practice nurses. Br J Sports Med
1998; 32: 242-247.
4 Eaton CB, Menard LM. A Systematic review of physical activity promotion
in primary care settings. Br J Sports Med 1998; 32: 11-16.
5 Stevens W, Hillsdon M, Thorogood M, McArdle D. Cost-effectiveness of a
primary care based physical activity intervention in 45-74 year old men
and women: a randomised control trial. Br J Sports Med 1998; 32: 236-241.
Competing interests: No competing interests
Editor- Harland and colleagues report on an attempt to promote
physical activity in one general practice1. Their choice of sessions of
vigorous activity as part of their main outcome measure was a surprising
perpetuation of a common misconception.
It has been clear for some time
that regular moderate-intensity (rather than vigorous) physical activity
provides substantial health benefits, and that low- to moderate-intensity
levels of activity are more likely to be continued than high-intensity
activities2,3. In addition, levels of habitual physical activity in the
general population are so low that to most people the prospect of vigorous
activity is a major turn-off. Given that the health benefits gained from
increased activity depend on the initial activity level, a more valuable
approach would have been to focus on the number of subjects achieving the
transition from sedentary state to regular moderate-intensity physical
activity.
Whilst accepting that the entry criteria to a research project may not
always reflect practice in the real world, the fact that Harland and
colleagues excluded one-third of patients from participation on health
grounds seems like another lost opportunity. It is known that most adults
do not need to see their physician4 before starting a moderate-intensity
physical activity program. Those subjects excluded by Harland because of
acute myocardial infarction within the last 12 months, angina and
cerebrovascular disease are precisely the group that should be receiving
strong positive encouragement from their physicians to be regularly
physically active5.
Marion McMurdo
Professor of Ageing and Health
Department of Medicine, Ninewells Hospital and Medical School, Dundee DD1
9SY
Competing interest: METM is co-director of D D Developments, a
University of Dundee company whose mission is to provide exercise classes
for older people, and the profits of which support research into ageing
and health.
1. Harland J, White M, Drinkwater C, Chinn D, Farr L, Howell D. The
Newcastle exercise project: a randomised controlled trial of methods to
promote physical activity in primary care. BMJ 1999;319:828-32. (25
September)
2. Physical Activity and Public Health. A recommendation from the
Centers for Disease Control and Prevention and the American College of
Sports Medicine. JAMA 1995;273:402-407.
3. Pollock ML. Prescribing exercise for fitness adherence. In:Dishman
RK, ed.Exercise Adherence, Champaign, Ill: Human Kinetics
Publishers;1988:259-277.
4. American College of Sports Medicine. Guidelines for exercise
testing and prescription.4th ed. Philadelphia, Pa: Lea and Febiger; 1991.
5. Wannamethee G, Shaper AG. Physical activity and stroke in middle
aged British men. BMJ 1992;304:597-601.
Competing interests: No competing interests
Newcastle exercise project
EDITOR-Harland et al ably highlight the short-comings of exercise
prescriptions as a means of promoting physical activity as used in the
U.K. The long-term adherence of patients prescribed 'leisure centre' type
referrals in their study even in the group with the most intensive
intervention coupled with financial incentive, as in other studies (1) is
disappointingly low. It mirrors exactly our experience with our own
scheme. The proliferation of such schemes surely results from a
combination of good intentions, ease of setting up, and most particularly
because they have been cost-neutral to the scarce resources of the NHS.
There are well-documented exercise prescription schemes of a different
type being practiced in Europe and the US, often home-based, informal and
unsupervised with limited intervention, which nevertheless yield good long
-term outcomes and rates of adherence (2). There may subtle cultural
reasons why such practice may not easily transfer to the U.K. Yet, given
the well established health and social benefits associated with increased
physical activity these types of schemes deserve evaluation here before
prescribing exercise is labeled ineffective.
Mark Reeves
general practitioner
Trescobeas Surgery, Falmouth, Cornwall TR11 2UN.
1) Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The
Newcastle Exercise Project: a randomised controlled trial of methods to
promote physical activity in primary care.BMJ 1999;319:828-832.
2) Taylor AH. Evaluating GP exercise referral schemes: findings from
a randomised control study. Eastbourne: University of Brighton, 1996.
3) Hillsdon M ,Thorogood M, Antiss T, Morris J. Randomised controlled
trials of physical activity promotion in free living populations: a
review. J Epidemiol Community Health 1995: 49: 448-453.
Competing interests: No competing interests