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;319:828Data supplement
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, Denise Howel
Health Promotion Research Group, School of Health Sciences, Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HHJane Harland
research associate
Martin White
senior lecturer in public health
Chris Drinkwater
senior lecturer in primary health care
Lorna Farr
research associate
Department of Physiological Sciences, Medical SchoolDavid Chinn
senior research associate
Department of Epidemiology and Public Health, University of Newcastle upon TyneDenise Howel
senior lecturer in epidemiological statistics
Correspondence to: Jane Harland j.o.e.harland{at}newcastle.ac.uk
Abstract
ObjectiveTo evaluate the effectiveness of combinations of three methods to promote physical activity.
DesignRandomised controlled trial. Baseline assessment with follow up 12 weeks and 1 year after intervention.
SettingOne urban general practice, 1995-7.
Participants523 adults aged 40 to 64 years, randomised to four intervention groups and a control group.
InterventionsBrief (one interview) or intensive (six interviews over 12 weeks) motivational interviewing based on the stages of change model of behaviour change, with or without financial incentive (30 vouchers entitling free access to leisure facilities).
Main outcome measuresPhysical activity score; sessions of moderate and vigorous activity in the preceding four weeks.
ResultsResponse rate was 81% at 12 weeks and 85% at one year. More participants in the intervention group reported increased physical activity scores at 12 weeks than controls (38% v 16%, difference 22%, 95% confidence interval for difference 13% to 32%), with a 55% increase observed in those offered six interviews plus vouchers. Vigorous activity increased in 29% of intervention participants and 11% of controls (difference 18%, 10% to 26%), but differences between the intervention groups were not significant. Short term increases in activity were not sustained, regardless of intensity of intervention.
ConclusionsThe most effective intervention for promoting adoptionof exercise was the most intensive. Even this did not promote long term adherence to exercise. Brief interventions promoting physical activity that are used by many schemes in the United Kingdom are of questionable effectiveness.
Introduction
Regular physical activity protects against cardiovascular diseases, obesity, diabetes, and osteoporosis (1) and helps promote mental health. (2) In the United Kingdom, 70% of men and 80% of women are insufficiently active to benefit their health. (3) Promoting physical activity has been described as "today’s best buy in public health terms" (4) and interventions based in primary care that promote physical activity have become increasingly popular—over 200 "exercise on prescription" schemes have been identified in England. (5) However, few have been rigorously evaluated, (6)(7) and the need for trials has been highlighted. (5)(7) (8) (9) (10) We present results from a randomised controlled trial evaluating the effectiveness of promoting physical activity in primary care.
Methods
Participants
Participants were recruited from one general practice (list size 11 400) situated in a socioeconomically disadvantaged area of Newcastle. (11)(12)All patients aged 40 to 64 years who were registered at the practice on 1 January 1995 and satisfied our inclusion criteria were eligible to participate. Exclusion criteria related primarily to safe exercise testing (see table 1), which gives further details of the exclusion criteria and numbers excluded). Patients unable to complete a submaximal exercise test were excluded (patients with cardiovascular or respiratory disease causing raised risk), as were patients undertaking regular vigorous exercise at least three times a week over the previous six months.
Recruitment
Between March 1995 and March 1996 the researcher (JH) approached all patients aged 40-64 attending routine surgeries. Patients completed a recruitment card, signed by their general practitioner, which they returned to the researcher before leaving. Postal recruitment was introduced between March and August 1996 to boost declining opportunistic recruitment. Patients not previously approached opportunistically were identified from the practice register, checked for eligibility, and sent a postal invitation to participate.
Data collection
Data were collected in three phases: baseline assessment; post-intervention follow up 12 weeks after baseline (postal questionnaire); and repeat assessment one year after baseline, at which assessors were blind to allocated group (see figure ). Baseline and follow up assessments lasted 75 minutes and included a structured interview questionnaire, physical measurements, and exercise test (cycle ergometer). Participants who refused the one year assessment were sent a follow up questionnaire. All non-respondents received one telephone reminder and two written reminders, as required. Our null hypothesis was that changes in self reported physical activity at follow up would be the same in the intervention and control arms.
Outcome measures
Self reported physical activity was assessed by using a shortened version of the National Fitness Survey questionnaire that included questions on the type, frequency, duration and intensity of different activities in the previous four weeks. (3)(13) Activities were categorised as moderate, expending 5-7.5 kcal/min (0.209-0.314 MJ/min), or vigorous, expending >7.5 kcal/min (>0.314 MJ/min). (3)(14)(15) A physical activity score was based on the number of sessions of moderate and vigorous activity lasting a minimum of 20 minutes in the previous four weeks. The score included all walking, cycling, and other sports or leisure activities but excluded home based activities (housework, gardening, and "do it yourself"). Scores were computed for respondents with complete physical activity data at each time period. Anthropometric, physiological, and other related outcomes, including changes in the variables of the exercise test, will be reported separately.
Randomisation
After their baseline assessment, participants were randomised individually to intervention and control groups. To maintain equal numbers in each group, they were randomised in blocks of 10. They chose blind from a set of 10 randomly ordered cards (two for each number from one to five, corresponding to the control group and four intervention groups) and were allocated to the corresponding group.The cards were not replaced in the pack until all 10 had been chosen.
Interventions
All participants 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 (smoking, alcohol, weight, and diet), recommended activity levels for men and women of different ages, (3) and 19 leaflets on leisure facilities and activities available locally. Brief advice was given, comparing the individual’s results with recommended levels and highlighting details in the information pack. Those in the control group received no further intervention.
Participants randomised to receive brief intervention (interventions 1 and 2) were offered one motivational interview within two weeks of their baseline assessment. Those receiving intervention 2 received 30 vouchers at the interview. Participants randomised to receive intensive intervention (interventions 3 and 4) were offered six motivational interviews over 12 weeks, the first within two weeks of the baseline assessment. Those in intervention 4 also received 30 vouchers at the first interview.
Motivational interviewing
Motivational interviewing is a technique for negotiating behaviour change with people who are reluctant or ambivalent about changing. (16) The aim is to increase their intrinsic motivation, so that change arises from within rather than being imposed from without. The technique uses the stages of change model of behaviour change. (17) (18) (19) (20) (21) During interviews, the interviewer uses skills and strategies which are tailored to the participant’s position on the cycle of behaviour change to initiate and facilitate change. Some of these techniques are derived from client centred counselling. (16)
A health visitor (LF) delivered all the motivational interviews. She received 14 hours (seven sessions) training in negotiating behaviour change from a clinical psychologist. (16) Interviews were scheduled to last 40 minutes and took place at the practice or local leisure centre. They aimed to promote safe, effective physical activity but did not prescribe particular activities; instead participants were free to choose lifestyle or facility based activities(those not requiring special facilities or those that do need special facilities, respectively) that suited their circumstances and preference. Interviews included information about the trial and role of the interviewer; a review of baseline results, current activity, perceived benefits of and barriers to exercise; understanding of safe, effective (aerobic) activity and related health benefits; development of a personalised physical activity plan; and exploration of other health related issues raised by the participant. A structured record was completed at each interview, a copy of which was given to participants; this was used to review progress for those attending more than one interview.
Financial incentive
Barriers to leisure time activity vary by age (3) and socioeconomic position. (22)(23) One of the main barriers for lower socioeconomic groups is cost. (24) To overcome this, we provided 30 non-transferable vouchers valid during the intervention period. Vouchers could be exchanged for one episode of most aerobic activities in any local authority leisure centre, swimming pool, or other voluntary or community leisure activity in Newcastle. Date, place of use, and activity were recorded.
Analysis
A successful outcome was defined as moving up one or more levels of physical activity score from baseline to follow up. We calculated that 107 participants per group would be required to detect a difference between success rates of 40% to 60% at 80% power and 5% significance level.
Analysis, on the basis of intention to treat, was done with spss. (25) The ���2 test for differences in proportions was used to compare success rates across the five groups at follow up. If these showed significance (P<0.05), then the success rate in all intervention groups combined was compared with that in the control group. The rates within the intervention groups were compared by investigating the effect of extra interviews (interventions 1 and 2 combined versus interventions 3 and 4 combined), introduction of vouchers (interventions 1 and 3 combined versus interventions 2 and 4 combined), and interaction between extra interviews and vouchers, using logistic regression analysis. Confidence intervals for differences in proportions were calculated. (26)
Ethical approval was granted by Newcastle and North Tyneside Joint University and NHS Research Ethics Committee.
Results
Recruitment and response rates
In all, 2974 patients were approached (96% of those aged 40-64 years): 1308 opportunistically and 1666 by post (postal response rate 47%; figure). Of these, 477(16%) were excluded(412 (31%) opportunistic, 65 (4%) postal (table 1)) and 734 agreed to participate (531 (41%) opportunistic, 203 (12%) postal). In total, 217 men and 306 women were enrolled. Baseline characteristics were evenly distributed in control and intervention groups (table 2). Baseline levels of physical activity were low: 10% of men and 7% of women achieved age specific target levels of activity and only 15% of respondents had done any vigorous activity lasting at least 20 minutes in the previous four weeks. Fewer than 1% were employed in heavy manual work.
(Figure 1) Flow of participants
Table 1 Reasons for exclusion from study
Opportunistic recruitment (n=412)
Postal recruitment (n=65*)
Total (n=477)
No of patients' notes checked by general practitioners
1175
287
1462
Ineligible for fitness assessment:
Cardiovascular or respiratory disease causing raised risk:
Acute myocardial infarction in last 12 months
8
1
9
Triple therapy for angina
2
2
4
Arrhythmia
8
1
9
Angioplasty or cardiac surgery
5
0
5
Severe cardiac failure
2
0
2
Aortic valve disease
4
1
5
Cardiomyopathy or myocarditis
1
0
1
Stroke or transient ischaemic attack in last 12 months
10
5
15
Pulmonary embolism or venous thrombosis in the last 6 months
1
0
1
Blood pressure 180/105 mm Hg
11
0
11
Patient taking ß-blockers
96
15
111
Asthma or chronic obstructive airways disease (peak flow <300 l/min)
46
1
47
Severe anaemia (haemoglobin <90g/l)
2
0
2
Other serious morbidity
43
2
45
Orthopaedic or rheumatic conditions that make it impossible to pedal a bicycle
128
9
137
Aspergillosis (potential risk of equipment contamination)
1
0
1
Unsuitable for intervention:
Severe mental illness or learning disability
10
2
12
Known terminal illness
1
0
1
Doing sufficient exercise already
26
20
46
No reason given
7
2
9
*Excluding 114 patients who received a home visit from a their general practitioner in the previous month.
Table 2 Demographic and behavioural characteristics of participants at baseline. Values are numbers (percentages) of participants
Control (n=105)
Intervention 1 (n=105)
Intervention 2 (n=106)
Intervention 3 (n=104)
Intervention 4 (n=103)
All interventions (n=418)
Sex ratio (men:women)
44:56
36:64
42:58
41:59
45:55
41:59
Age group:
40-44
27 (26)
28 (27)
20 (19)
32 (31)
20 (19)
100 (24)
45-49
22 (21)
17 (16)
32 (30)
23 (22)
27 (26)
99 (24)
50-54
21 (20)
24 (23)
17 (16)
15 (14)
21 (20)
77 (18)
55-59
13 (12)
16 (15)
22 (21)
13 (13)
15 (15)
66 (16)
60-64
22 (21)
20 (19)
15 (14)
21 (20)
20 (19)
76 (18)
Marital status:
Single (never married)
8 (8)
10 (10)
8 (8)
6 (6)
4 (4)
28 (7)
Married or cohabiting
79 (75)
79 (75)
85 (81)
75 (72)
78 (76)
317 (76)
Widowed, divorced or separated
18 (17)
16 (15)
12 (11)
23 (22)
21 (20)
72 (17)
Occupational class:
Non-manual (I, II, III non-manual)
35 (34)
30 (29)
24 (23)
29 (28)
31 (30)
114 (27)
Manual (III manual, IV, V)
69 (66)
75 (71)
79 (77)
74 (72)
71 (70)
299 (72)
Employment status:
Employed full or part time or self employed
52 (50)
52 (50)
53 (50)
58 (56)
55 (53)
218 (52)
Unemployed and seeking work
13 (12)
11 (11)
17 (16)
6 (6)
7 (7)
41 (10)
Unable to work due to illness
15 (14)
17 (16)
13 (12)
14 (14)
12 (12)
56 (13)
Retired
12 (11)
18 (17)
10 (9)
13 (13)
19 (18)
60 (14)
Looking after home and family, or other
13 (12)
7 (7)
12 (11)
13 (13)
10 (10)
42 (10)
Housing tenure:
Owner occupier
57 (54)
68 (65)
60 (57)
57 (55)
62 (60)
247 (59)
Rented from city council
40 (38)
32 (31)
40 (38)
40 (39)
33 (32)
145 (35)
Rented privately
7 (7)
1 (1)
2 (2)
2 (2)
5 (5)
10 (2)
Other
1 (1)
4 (4)
4 (4)
5 (5)
3 (3)
16 (4)
Car and phone ownership:
Car owner
59 (56)
66 (63)
65 (61)
66 (64)
67 (65)
264 (63)
Phone owner
94 (90)
102 (97)
100 (94)
97 (93)
92 (89)
391 (94)
Age left full time education:
���14
12 (11)
8 (8)
8 (8)
13 (13)
12 (12)
41 (10)
15
64 (61)
64 (61)
64 (60)
60 (58)
65 (63)
253 (61)
16-18
29 (28)
31 (30)
28 (26)
29 (28)
19 (18)
107 (26)
���19
0 (0)
2 (2)
5 (5)
2 (2)
7 (7)
16 (4)
Physical activity score:
Level 0 (no sessions moderate or vigorous)
68 (65)
65 (62)
60 (58)
58 (56)
72 (70)
255 (61)
Level 1 (1-4 sessions moderate or vigorous)
20 (19)
20 (19)
19 (18)
21 (20)
15 (15)
75 (18)
Level 2 (5-11 sessions moderate or vigorous)
8 (8)
8 (8)
14 (14)
10 (10)
10 (10)
42 (10)
Level 3 (���12 sessions moderate)
5 (5)
7 (7)
4 (4)
9 (9)
1 (1)
21 (5)
Level 4 (���12 sessions moderate or vigorous)
1 (1)
4 (4)
3 (3)
3 (3)
4 (4)
14 (3)
Level 5 (���12 sessions vigorous)
3 (3)
1 (1)
4 (4)
3 (3)
1 (1)
9 (2)
Achieving target level of activity:
Yes
6 (6)
7 (7)
11 (11)
13 (13)
6 (6)
37 (9)
No
99 (94)
98 (93)
93 (89)
91 (88)
97 (94)
379 (91)
Intervention 1: one motivational interview within two weeks of baseline assessment; intervention 2: one motivational interview within two weeks of baseline assessment plus 30 vouchers; intervention 3: six motivational interviews over 12 weeks; intervention 4: six motivational interviews over 12 weeks plus 30 vouchers.
The response rate at 12 weeks was 81% (n=424). Response at one year was 85% (n=442); 61% (321) attended the repeat assessment and 23% (121) completed the postal questionnaire. Differences in response rates at 12 weeks and one year between intervention groups were not significant.
Uptake of interventions
Among participants in the intervention group, 341 (82%) attended at least one interview (figure ). Attendance was higher in the interventions that included vouchers than the other interventions, (86% (180) v 77% (161)). Among participants offered six interviews, the median number of interviews attended was three; only eight participants (4%) attended all six.
Of the 180 participants receiving vouchers, 41% (74) used at least one (figure ). Use of vouchers was higher in the intensive intervention group than the brief intervention group (44% (45) v 27% (29)). Only two people used all 30 vouchers. In total, 670 vouchers were exchanged at three out of a possible 30 venues; 69% (463) at the leisure centre nearest to the practice, 29% (196) at the local swimming pool, and 2% (11) at another swimming pool nearby.
Main outcomes
At 12 weeks
The proportions with improved physical activity scores differed significantly in the four intervention groups combined, compared with the controls (38% (123) v 16% (13), P=0.001) (table 3). Within the intervention groups, no significant effect was due to the introduction of vouchers (P=0.84) or more than one interview (P=0.26), but there was a significant interaction between these interventions (P=0.01): the highest proportion of participants with increased physical activity scores (55%) was in the group offered both multiple interviews and vouchers. This was 39% (95% confidence interval 25% to 53%) more than in the control group.
Table 3 Number (percentage*) of participants with improvements in self reported measures of physical activity at 12 weeks and 1 year
Control
Intervention
P value†
Intervention
P value‡
1
2
3
4
1-4
Outcome at 12 weeks compared with baseline
(n=89)
(n=88)
(n=84)
(n=83)
(n=80)
(n=335)
Increased physical activity score††
13 (16)
31 (36)
22 (28)
28 (35)
42 (55)
<0.001
123 (38)
<0.001
Increased total sessions of vigorous activity
9 (11)
22 (26)
14 (18)
26 (31)
32 (40)
<0.001
94 (29)
<0.001
Increased total sessions of moderate activity
11 (13)
27 (31)
19 (24)
24 (30)
28 (36)
0.040
98 (30)
0.002
% difference (95% CI for difference) compared with control group
Increased physical activity score††
20 (8 to 33)
12 (0 to 25)
19 (6 to 32)
39 (25 to 53)
22 (13 to 32)
Increased total sessions of vigorous activity
15 (4 to 26)
7 (-4 to 18)
21 (9 to 33)
29 (17 to 42)
18 (10 to 26)
Increased total sessions of moderate activity
18 (6 to 30)
11 (-1 to 22)
16 (4 to 29)
23 (10 to 36)
17 (8 to 26)
Outcome at 1 year compared to baseline
Outcome at 1 year compared with baseline
(n= 91)
(n= 96)
(n= 88)
(n= 88)
(n= 79)
(n= 351)
Increased physical activity score††
21 (23)
22 (23)
22 (26)
27 (31)
21 (27)
0.727
92 (26)
—
Increased total sessions of vigorous activity
11 (12)
17 (18)
19 (22)
19 (22)
14 (18)
0.425
69 (20)
—
Increased total sessions of moderate activity
17 (19)
20 (21)
18 (21)
23 (26)
15 (19)
0.732
76 (22)
—
% difference (95% CI for difference) compared with control group
Increased physical activity score††
0 (-12 to 12)
3 (-10 to 15)
8 (-5 to 21)
4 (-10 to 17)
3 (-7 to 13)
Increased total sessions of vigorous activity
6 (-5 to 16)
10 (-1 to 21)
10(-12 to 21)
6 (-5 to 16)
8 (-0 to 16)
Increased total sessions of moderate activity
22 (-9 to 14)
23(-10 to 14)
8 (-5 to 20)
0 (-12 to 12)
3(-6 to 12)
Intervention 1: one motivational interview within two weeks of baseline assessment; intervention 2: one motivational interview within two weeks of baseline assessment plus 30 vouchers; intervention 3: six motivational interviews over 12 weeks; intervention 4: six motivational interviews over 12 weeks plus 30 vouchers.
*Calculated using total respondents with complete data for each variable as the denominator .
†χ2 test for proportions comparing five groups.
‡χ2 test for proportions comparing intervention and control arms.
††Defined as moving up one or more levels of physical activity score from baseline to follow up.
The proportion of participants with an improvement in vigorous activity was significantly higher in the four intervention groups combined than the control group (29% (94) v 11% (9), P<0.001; difference 18%, 10% to 26%). However, within the four intervention groups there were no significant effects due to interviews (P=0.40), vouchers (P=0.21), or the interaction between them (P=0.09). The improvement inmoderate activity was greater by a worthwhile amount in the four intervention groups than the control group (30% (98) v 13% (11), P=0.002; difference 17%, 8% to 26%). However, there was no significant effect due to interviews (P=0.80), vouchers (P=0.27), or the interaction effect between them (P=0.16). The data were consistent with a worthwhile positive effect of intervention compared with the control group.
At one year
Increases in physical activity reported at 12 weeks by participants in the intervention group were not maintained at one year, regardless of the intensity of intervention. Only the increase in vigorous activity in the intervention groups was close to statistical significance. The data were consistent with small positive or negative effects of intervention groups compared with controls.
Discussion
Adoption of physical activity (initiation of increased physical activity in previously sedentary individuals) and adherence to physical activity (long term maintenance of increased physical activity) have been described as distinct phases of activity behaviour influenced by different factors. (27)(28) This trial evaluated interventions to promote adoption of physical activity in socioeconomically disadvantaged, middle aged adults. The most effective intervention was the most intensive, apparently due to synergy between motivational interviewing and financial incentive. A comparatively brief intervention (one motivational interview) was effective for only a third of participants in the short term. Results at one year showed that short term increases in physical activity were not maintained. Even the most intensive intervention was ineffective in promoting adherenceto exercise in the absence of further incentives to maintain changes in lifestyle.
Limitations
The study was experimental, (29) with most of the recruitment, intervention, and evaluation functions undertaken by research staff. Our recruitment rate (17%) was considerably higher than other exercise on prescription schemes, which have typically involved less than 1% of the patient base from which they were drawn (5); this may have been facilitated by the researcher being in the practice to initiate recruitment daily.
Opportunistic recruitment was effective initially but led to diminishing returns as the number of eligible patients fell from 20 to three per surgery over a year. About a third of these patients were excluded, the majority on health grounds. Postal recruitment enabled further participants to be enrolled, but they were more likely to be in employment and in better health. (30) Although opportunistic recruitment consumed more resources in terms of time and missed appointments, it seems to have targeted those with more to gain from participation in physical activity than did postal recruitment. Recruitment rates have been shown to affect the cost effectiveness of physical activity interventions. (31) Further research is required to develop recruitment strategies tailored to different population subgroups.
Participants were recruited from an area with high levels of socioeconomic disadvantage. As physical activity, and perceived barriers to physical activity, vary with socioeconomic status, (23) the effectiveness of the interventions may vary in different population subgroups. Patients enrolled in the trial represent those most willing to comply. Response rates at follow up are likely to be higher than expected in a normal primary care setting, but they provide insight into the likely uptake of physical activity promotion offered as routine preventive care.
Exercise testing at baseline and one year excluded patients who could otherwise have participated and potentially benefited from increased physical activity. The baseline assessment received by participants in the control group represents a considerable intervention and may have diluted the apparent results of the intervention. The proportion in the control group reporting increased physical activity at one year (23%) is higher than that in a similar trial where the control group received information only (23% v 13%). (31) Access to surgery premises was restricted to surgery hours, which may have excluded patients in full time employment and contributed to a reduced response at one year. Though this reflects the reality of general practice, alternative strategies may be necessary to target working populations—for example, in work places or during evenings and weekends. Outcome measures were based on self reported data and may be subject to reporting bias.
Implications
The results of this trial have important implications for the organisation and effectiveness of exercise referral and prescription schemes. (5) (6) (7)
Our results suggest that only a third of participants in physical activity promotion schemes are likely to adopt increased physical activity in response to a brief intervention. This proportion may be increased by the use of intensive motivational interviewing and financial incentives in combination. However, any short term increases in physical activity are unlikely to be maintained in the longer term. In light of these findings, primary healthcare teams need to assess critically the interventions that are currently used to promote physical activity, and they should reconsider the use of scarce resources to fund "exercise prescription" or "exercise referral" schemes. Further research is needed to develop interventions that promote long term adherence to exercise in addition to adoption of exercise and to identify less costly ways of delivering these, including alternative methods for providing long term support, such as telephone calls or physical activity diaries. (27)(32)
There is a need to base policy on evidence, and not simply on fashion and the apparent popularity of current schemes. This is particularly important given the increasing emphasis placed on physical activity by current government initiatives in Britain such as Healthy Living Centres. (33)(34)
Key messages
- Schemes promoting physical activity are currently popular in general practice in Britain, but few have been rigorously evaluated and their effectiveness is unknown.
- In this study, the most effective intervention for promoting adoption of physical activity was the most intensive, involving six motivational interviews and a financial incentive
- A comparatively brief intervention (one interview) was only effective in the short term in around a third of participants
- Short term increases in physical activity were not maintained at one year follow up and even the most intensive intervention was ineffective in promoting long term adherenceto increased physical activity.
- National and local government, health authorities, and primary healthcare teams should be cautious about current and future expenditure on, and implementation of, exercise prescription or referral schemes
We thank all the staff at Walker Medical Group; Linda Norris, at Community and Leisure Services, Newcastle City Council; Drs Jim Reed and Andy Binks, for help and advice with exercise testing; Wyn Raine, Janet Jewitt, and Marion Hancock for secretarial support; Peter James for providing training in motivational interviewing and support to Lorna Farr; Josie Wilson for help with data processing and collection; all the staff at the Lightfoot Leisure Centre. Lastly we would like to express our special thanks to all of the participating patients from Walker Medical Group for their time and support.
Contributors: MW and CD conceived the study and obtained funding in collaboration with DH. JH further developed the study design and, with DC and LFr, collected and processed the data. LF was responsible for implementing the interventions. Data analysis was carried out by JH and DH, with advice from MW and DC. JH and MW were responsible for drafting this paper, with contributions from DH. All authors contributed to data interpretation and commented on drafts of the paper. JH, MW, and CD are guarantors.
Funding:The Newcastle exercise project was funded by the NHS National R&D Programme on Cardiovascular Disease and Stroke (grant number HB32).
Competing interests: None declared.
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(Accepted 29 July 1999)
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