The Physical Activity of Children and Youth: Outcomes of Participation
Scientific Summary of Psychosocial Outcomes
Lawrence R. Brawley, Ph.D.
Nicole Culos-Reed, M.A.
SSHRC - Ph.D. Fellowship
Department of Kinesiology
University of Waterloo
Waterloo, Ontario
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or
transmitted in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise without prior written permission of the Canadian Society for Exercise Physiology.
The purpose of this document is to provide summary information about the psychosocial
benefits of physical activity for children and youth. This information will be presented as a
result of the conclusions drawn from a scientific review of the literature concerning the
psychosocial outcomes of participation in regular physical activity by children and youth. A
review of the relevant literature was conducted by first gathering necessary resources. The
following procedures were undertaken
a)
online retrieval and library search using medline, social sciences, citation index,
psychological abstracts, key journals, advice of recognized experts. A specific search of
the latest literature for the past five years was conducted given that several major reviews
were conducted prior to 1995. Topics searched were of a broad range that targeted
physical activity or exercise and psychological variables in children and adolescents. The
most frequently identified variables were self-efficacy, self-esteem, internal locus of
control, depression anxiety, stress, hostility/anger, psychiatric disorders, and
intellectual/cognitive functioning.
b)
retrieval of existing reviews and consensus statements over the last six years. In some
cases these reviews span the previous two decades (1976-present).
c)
review of literature not included in major reviews (six studies published in 1998 and
1999).
d)
review of interventions where psychosocial outcomes were secondary or ancillary
outcome (i.e., participation rate-primary outcome).
As with the scientific review for the original Canadian Guide for Healthy Physical
Activity, we will present outcomes in summary form rather than as a narrative review. The latter
review would simply constitute a repetition of existing reviews. The purpose of the presentation
is to summarize those outcomes that are (a) reliably forthcoming as a result of participation (i.e.,
findings based upon substantive evidence) (b) promising, but based upon limited data (c) unique,
but require more research.
Relative to the much larger body of evidence available to consider for adults and more
recently, for the elderly, the literature addressing psychosocial outcomes for children/youth is
very limited. As well, there are a number of problems with the existing literature such that this
evidence must be viewed cautiously. This is because (a) the quality of the evidence is uneven
across different outcomes and studies. (b) many of the studies are correlational in nature. making
it difficult to infer cause and effect, (c) many of the studies are short term in nature limiting a
developmental perspective regarding the effects of physical activity, (d) the results of studies in
some specific areas of psychosocial outcomes are equivocal. In fact, the criticisms that have
been offered about different aspects of the psychosocial literature might be some of the most
generalizable facts that can be observed.
Target Audience and Deliverv Mechanism
Although children and youth are the targets for a change in both physical activity and
associated health outcomes (i.e., physical and psychosocial) as yet no target audience(s) and
delivery mechanism(s) have been established for this Guide. This is an important point whatever
form the guide may take in terms of a physical product (i.e. visual text poster, guidebooks,
brochure, video). There will be a need to match the information that the product contains with
the target audience. Although children and youth are outcome targets. many intervention targets
may be adults who "deliver". "promote" and "program" Guide messages. Therefore, any
development of products in advance of construction of a children's and youth Guide may neither
complement the target individuals who are delivery agents nor the mode of delivery (e.g,
curriculum change in school: computer-self-rating for youth). Further, the recommendation of
an intervention can not be made without considering these issues and the financial resources that
might be used to conduct an intervention with the Physical Activity Guide for Children and
Youth.
Realistic Outcome
Commensurate with age level, presentation of a written/verbal message alone may
generate some limited outcomes among children and youth. However. the delivery and
3
presentation of the message will require social persuasion techniques to enhance
attention/retention and actions. Outcomes will depend. in part upon (a) the social context in
which the message is delivered (e.g .. school, family, medical), (b) opportunities for repeated
message exposure and action in that context, (c) the strength of sources of social reinforcement
for acting on the message, (d) whether the outcomes are measurable, and the (e) proximity of
these outcomes to the message.
Outcomes for children and youth that are not realistic as a direct result of the messages in
the guide are:
short term changes in health status
•
marked improvements in regular physical activity in the population of children and youth
•
marked long term changes in psychological well being
The Guide should be one part of a comprehensive strategy to affect children and youth.
Consideration of how the information in the Guide is delivered, by whom. the various formats of
the information presentation and the channels for Guide delivery will be part of that
comprehensive strategy, should it be adopted.
Summary of Studies and Reviews
Six previously reported reviews of the literature have been published on the
psychological benefits of physical activity in children. Most of these reviews were narrative, and
one was a meta-analysis (Calfas & Taylor, 1994). One of the narrative reviews reported on the
recent as well as an earlier meta-analysis.
The majority of studies contained in the reviews were of a cross-sectional, observational
nature. The number of studies that include prospective (longitudinal) designs with random
assignment to groups are few. Five of the cross-sectional studies were randomized training
studies with small sample sizes.
Three of the reviews examined literature that concerned both children and adolescents,
two of the reviews focused on children and one examined only adolescents. The number of
studies examined in each review ranged from as few as eight to as many as twenty. Some of the
4
reviews were clearly overlapping in terms of the results they reported.
Physical Activitv and Mental Health Problems
No evidence of a risk to mental health was demonstrated in the reviews we examined.
However, studies where subjects were exposed to high risk/stress conditions were not found
(e.g., elite sport, high training load studies).
The meta-analysis (Gruber, 1986) reporting on studies prior to 1986 found a negative
association between physical activity and (a) anxiety/stress, and (b) depression with effect sizes
of 0.34 for normal, pre-adolescent samples and 0.57 for handicapped individuals). Fitness
activities seemed to yield the largest outcome effect. Large effects were also reported for those
whose psychological well being was at a lower initial level (i.e .. handicapped).
Some concern has been raised in a few studies with competitive athletes (in specific
sports) regarding an association between participation and eating disorder responses. However,
from a public health viewpoint, there is not evidence that there should be a concern for
individuals involved in activities that would be considered general participation.
Moderate size effects were reported the more recent meta-analysis (Calfas & Taylor,
1994) for the relationship between physical activity and (a) anxiety: ES= [-.15], and (b)
depression: ES= [-.38] in. However. only five randomized controlled trials were analyzed out of
the 20 studies examined. The effects are similar to those reported for adults for regular physical
activity (cf. Adult Guide). No conclusion can be drawn about the specific activity dose-response
relationship for psychosocial outcomes. The only conclusion that can be drawn is that the
relationships were observed in regular physical activity and that these observations were drawn
mainly from the more numerous short term studies (as reported in the 1986 and 1994 metaanalyses). Two other narrative reviews reported the same negative association between physical
activity and those mental health variables.
Summary: Physical Activitv and Mental Health Problems
•
Moderate negative relationships between regular. but not necessarily, longitudinal
physical activity and
5
stress. anxiety (nonclinical)
nonclincial (transitory) depression
A negative relationship may not be just the increase of physical activity and the decrease
of a nonclinical problem. It may also be due. for example. to lower physical activity due
to health symptoms and higher values of depression or stress/anxiety.
•
Absence of systematic evidence in using exercise as part of the treatment for clinical
mental health problems or for problems of physical diseases where psychological/mental
effects are outcomes that are systematically observed (i.e., as either primary or secondary
outcomes).
Physical Activitv and Mental Health Promotion
In general, the six recent reviews support consistent, positive associations between
participation in physical acti vi ty and various aspects of mental well-being. The studies examined
by the various narrative and meta-analytic reviews have designs that range from experimental
control to cross-sectional correlational to epidemiological
As well, six recent studies since 1994 ( 1998/1999) provided evidence for the same type
of finding. Most of these studies were conducted in the school system. Five of these were crosssectional. Two of the studies were conducted with relatively small samples of children
to 150:
s" and 6 th grade).
en = 100
The other three studies were large sample studies conducted with
adolescents (aged 15 - 20: D = 852 to 9268). Only one study was longitudinal and based upon a
theoretical model (smaller sample, D = l32: 5 th to 8 grade).
The meta-analytic reviews provide the strongest support for a link between participation
in regular physical activity and self-esteem. The narrative reviews provide reliable observations
of the relationship between physical activity and self-efficacy as do four of the recent activity
studies.
Summarv: Phvsical Activitv and Mental Health Problems
•
Reliable positive relationships between regular physical activity and self-esteem.
•
Reliable positive relationships between self-efficacy and participation in regular physical
6
activity for both children and adolescents.
There is insufficient_research to draw conclusions about the moderating effects of type of
exercise, individual differences, and social factors that might moderate the self-efficacyphysical activity relationship.
•
For adolescents who are active at least three times per week, fewer somatic (physical
symptom) health complaints are reported. These individuals also have perceptions of
greater confidence in their future health and report greater well being than nonactive
participants (i.e., observations from one large sample epidemiological study).
Cognitive and Academic Outcomes
Mutrie and Parfitt's (1998) recent review noted that there is some evidence that physical
activity improves academic and cognitive performance in youth. However, the evidence is of
uneven quality. During the 1990's, there was strong interest in research that concerned daily
physical education programs for children and outcomes of academic and physical performance
were assessed. However, there was little evidence of beneficial effects in the research.
On the other hand, Shephard's article in Pediatric Exercise Science (1997) contained a
report of longitudinal studies (3) and he concluded that academic performance was maintained
when there was an increase in the habitual physical activity of students, despite a reduction for
time in the curriculum or free time for academic study. However, he also added that the
introduction of daily programs of physical education should not be justified with the expectation
of major enhancements in academic performance.
Social and Moral Outcomes
From a developmental perspective, authors of physical activity texts and developmental
social psychology texts favor group-related, play experiences in early childhood as a forum for
social skills formation. Sport experience (both competitive and noncompetitive), physical
education classes, and exercise classes all present opportunities for social development.
Examples abound of statements by educators and government officials who argue that sport can
7
lead to the development of correct moral values and positive social skills (cf. Mutrie & Parfitt,
1998).
However. the empirical literature that either supports or refutes these notions is both hard
to detect and of uneven quality (Murrie & Parfitt, 1998). Some analyses of specific sports (i.e.,
selective samples of sports where aggressive physical behavior is highly visible) have led to the
conclusion that these situations promote a different, perhaps unacceptable, moral code. Again,
few controlled or observational studies are available. More recently, Beller and Stoll's (1995)
investigation of a large sample of U.S. high school students revealed that male team sports
athletes had lower levels of moral reasoning than either male or female nonathletes or female
team sport competitors. However, their sampling, definitions of who was an athlete, and
selective comparisons may be raised as potential limitations of this finding.
Finally, Lee (as reported in Mutrie & Parfitt, 1998) has raised the issue of whether sport
and physical education can contribute to moral development. He notes that positive outcomes in
this area are likely a result of complex interactions within coaching/teaching situations.
Certainly, social psychological research has underscored this point in both educational
settings and physical activity contexts. For example, Robert Rosenthal and colleagues (cf.
Rosenthal & Jacobson, L .. 1968) demonstrated the powerful effects of teacher expectancies and
related student behaviors in creating both a positive social context for learning, and fulfilling
both positive and negative teacher expectancies of students. The Sherif's and their colleagues
(1969) examined 9-12 year-old boys in several outdoor camp studies where physical activity was
a central objective. They demonstrated both the positive and negative effects of children
participating in competitive/cooperative physical activity environments. Physical activity
participation alone cannot be targeted as the sole cause of positive or negative outcomes. The
specific, complex social environment that accompanies participation includes agents that
contribute to these outcomes.
In relation to a more specific form of social and moral behavior, juvenile delinquency,
there have been some studies in the 1980's reporting a negative association between delinquency
8
and participation in physical activity. However, selective sampling of sport participants argues
against a conclusion that there is an association (i.e., delinquents may be less likely to be
included in the sample if they are not involved in sport).
In Mutrie and Parfitts review (1998), a small sample randomized controlled trial (ReT)
and a recent longitudinal study reveal conflicting findings with this work. In the longitudinal
study of youth, age and continued sport involvement were associated with higher probabilities of
delinquency. The small sample RCT demonstrated that if the social norms of the sport were
altered (i.e., in a combative sport when a physical and mental discipline perspective was replaced
with a self-defense perspective) indicants of social behavior were altered. Murrie and Parfitt's
( 1998) review concluded that further evidence of a controlled and/or longitudinal nature was
necessary to determine if there is support for the claim that participating in physical activity has a
causal influence on social and moral behavior. The moderating effects of the social environment
created by participants and supporting people, as well by the social-cultural context must also be
examined. Based upon the equivocal results available in reviews, the relationships between
social and moral behavior and participation in physical activity may well be very complex.
Without studies of moderators and without both sociological and psychological theoretical
foundations as the bases of study, reliable answers will remain elusive.
Summarv: Cognitive/Academic and Social/Moral Outcomes
•
Modest suggestive evidence of a positive relationship between physical activity and
cognitive/academic performance for youth. Apply a cautious interpretation due to the
lack of longitudinal RCT's.
•
No evidence of physical education hindering academic performance.
Equivocal evidence regarding a negative relationship between participation in physical
activity and juvenile delinquency.
Empirical evidence is scarce that suggests that involvement in physical activity
contributes to social and moral development. Much of this literature tends to be rhetoric
or philosophy.
9
Intervention Studies
A variety of interventions to promote physical activity in children and youth have been
examIned in the last 20 years. Once again. these studies vary in both design and the social
context in which the intervention was implemented. The three most common social contexts in
which physical activity interventions have been implemented are schools, communities, and
families. In most interventions, the primary outcomes are behavioral (i.e., amount of physical
activity, type, dose) or physiological/clinical (i.e., anthropometric measures. cardiovascular,
indices. body fat measures, muscle mass. exercise tolerance measures). Psychosocial outcomes,
if assessed are secondary measures or may be assessed as measures of process (i.e., between
intervention and outcome) called mediators. The examination of psychosocial mediators of the
effects of an intervention on an outcome is more the exception that the rule in the published
literature.
School-based Interventions. A narrative review was conducted by Almond and Harris
(1998) of 19 primary school and six secondary school interventions in a variety of countries.
These studies were conducted mainly during the past two decades. The review revealed seven
interventions that assessed "attitude change" toward physical activity. Four interventions
focused upon children, three upon youth. Most of the earlier interventions tended to be of less
than one years' s duration. Later interventions ( 1988 to present) tended to have a more
developmental perspective ranging from 1 years duration to 5 years. All interventions specified
at least one experimental and one control group. The most consistent finding was one of a
positive attitude toward physical education. physical fitness and physical activity. One large
sample Belgian study also reported a positive change in teacher's attitudes toward physical
education as well as a secondary outcome of increases in knowledge about fitness and health.
Recently, the conclusions of the American Congress of Sport Medicine's (ACSM)
speciality conference on physical activity interventions were published in the American Journal
of Preventive Medicine (1998), This special issue of reviews included a review by Stone,
McKenzie, Welk, and Booth (1998) on the effects of physical activity interventions in youth
10
(i.e., children and adolescents). Twenty-two studies were examined and all but three studies
were conducted in the U.S.A. None were conducted in Canada.
1)
Fourteen of these interventions were complete while eight revealed in progress findings,
2)
Fifteen studies were conducted in primary and secondary schools and colleges,
3)
For the complete interventions. eight studies concerned a grade or grades ranging
between 3 and 6, and
4)
Four studies concerned high school age youth and two studies were of college-age youth.
The study designs were quasi-experimental or experimental. The results in which the
author's placed the most confidence were those using randomized designs, valid and reliable
measurements, and extensive interventions. The most reliable psychosocial outcome from these
completed interventions was children's increased knowledge about their own bodies and about
physical activity and its benefits. Increased knowledge tended to be a primary outcome target
along with increased physical activity behavior. More specific knowledge about cardiovascular
disease was an intervention outcome for high school youth in the Stanford Adolescent Heart
Health Program (Killen et al, 1988).
Some of the outcomes in the school-based studies that are still in progress concerned
television viewing frequency and physical education knowledge changes. These may be
secondary outcomes given that some of these studies have. as their intervention, alterations of the
physical education curriculum or are computer mediated studies or have skills training
components. All of these are designed to increase the primary outcome of activity and/or
physical fitness.
Last, two studies of multiethnic, third and fourth grade students included measurement of
psychological mediating variables. Both concerned the two year "Go for Health" project
published in the early 1990's. Changes in the variables of exercise behavioral capability and
self-efficacy were detected but were very modest effects and these effects were observed in only
one of the two experimental schools examined. No examination of the relationship between the
mediator variables and changes in physical activity was conducted.
I1
The "CATCH" (Child and Adolescent Trial for Cardio-Vascular Health) trial intervention
was also reponed in the special issue by Baranowski and colleagues (1998). CATCH Trials
investigators, examined psychological of the intervention on physical activity outcomes for
children in grades 3-5 in 96 public schools in 4- different U.S. states. The mediators were social
support and self-efficacy for physical activity. Changes in the mediators were reported for
positive social support for activity for third and fourth grade students as well as for increased
self-efficacy for physical activity for these same grades. However, effects were very modest.
Once again, no relationship between the mediators and the outcome of increased physical
activity was examined.
Communitv-Based Interventions
Three major experimental/quasi-experimental studies were reported by Stone et al (1998).
Only one had knowledge change as a reported secondary outcome (i.e., change in knowledge of
cardiovascular health). All were multicornponent interventions.
Four "in progress" physical activity interventions were reported. One had a survey of
knowledge as a dependent variable. Each of these studies involves more than 200 students of
either african-american or multi-ethnic background. A second intervention called "Active
Winners" examined intentions to exercise as one of the dependent variables and found an
improvement in exercise intentions in african-american girls in grades 5-7 who were involved in
an after school and end of summer program.
Familv-Based Interventions
Sallis (1995, 1998) reported that at least three family-based health promotion interventions
involving normal healthy families have been conducted. Although these studies have involved
intensive interventions with strong designs, no change in the physical activity levels of family
members were observed.
However, other interventions that focused upon family members with lower baseline
activity levels and fitness levels (i.e., high health risk children, obese children) have demonstrated
changes (low fitness: Taggert et al, 1986; obesity: Epstein et al, 1984, 1990). The family
l2
intervention for obesity (i.e., counselling, diet. rewards, family support) is particularly interesting
because the initial weight loss evolved slowly over one to two years but was maintained for 10
years. Thus, family-based interventions show some promise with high risk children, including
those that focus upon psychosocial outcomes as well as outcomes of increased activity or
improved physical benefits.
Summarv: Intervention Studies
Few psychosocial outcomes were primary outcomes of intervention studies.
Most reliable change in a secondary outcome was children's increased knowledge of (a)
their own bodies relative to physical activity, and (b) physical activity and its benefits.
•
Some evidence indicates increased knowledge about cardiovascular disease in specifically
tailored studies focused on heart and health.
•
Modest effects of self-efficacy and social support were demonstrated in a few studies that
examined these variables as part of the mediating processes that link the intervention to
the outcome.
•
There is some limited evidence of an individual's physical activity being influenced by
family-oriented interventions. Specifically, modest changes in social support and selfefficacy for physical activity were evident following the intervention. However, no links
between these mediators and the outcome of physical activity were examined.
l3
Concensus on Recommendations for the Promotion of Phvsical Activitv and Fitness
"Exercise behavior is a complex and poorly understood phenomenon that probably
does not lend itself to single-phased, easy to implement intervention strategies" (p.
139. Pate. 1995)
The quote by Pate underscores the challenges for the promotion of physical activity for
children and youth. Furthermore. it sets up an expectation that there will be multiple
recommendations for promotion.
Pate, Trost, and Williams ~ 1998), noted that the US Centers for Disease Control and
Prevention ( 1997) offered 10 recommendations that either build upon or are consistent with
previously made recommendations of other concerned authors or groups (e ..g, American
Academy of Pediatrics, ACSM. Sallis. & Patrick. 1994, Sallis 1998). Pate et al (1998) reviewed
existing physical activity guidelines and took into account the scientific physiological and
behavioral evidence of participation. Based upon this foundation, they developed three major
recommendations for physical activity guidelines. These will not be repeated verbatim here but
can be summarized as follows.
1.
All children and youth should take part in at least moderate intensity physical activity for
an average of one hour per day. In general, daily activity can vary in type, setting,
amount. duration. and intensity.
2.
At least twice weekly, all children and youth should take part in activity that increases and
maintains muscular strength in the trunk and upper girdle, as part of the daily 60 minutes.
3.
All children and youth should meet the first two recommendations by participating in
developmentally appropriate physical activity (physiological and behavioral) of varied,
type, intensity, and duration.
Pate et al (1998) point out that these recommendations are not supported by the desired
amount of scientific evidence and are less reliably supported than recommendations made for
adults. They are. however. based upon a number of different consensus panels of experts in the
behavioral, physiological sciences and pediatric medicine.
14
Recommendations for Effective Promotion
Sallis ( 1995) has offered a perspective on approaches to promote regular physical activity
for children and youth. He notes that no approach has been demonstrated as being effective on a
large scale. Further, research promoting physical activity for children and youth is itself in
developmental stages.
A number of the reviews of the literature we examined included companion
recommendations for the promotion of physical activity for children and youth. These
recommendations, in many cases, are broad and are extensive. When matching the quality and
extent of the empirical evidence to the recommendations for promotion, there is a tendency to
make recommendations that go beyond the data. However, as Riddoch (1998) has noted...."for
the foreseeable future, we must rely at least as much on theory, common sense. observation and
expert opinion as on hard evidence." (p. 39)
In order to produce public health outcomes or developmental outcomes, regular adherence
to physical activity is necessary. Thus as noted by Riddoch in Biddle, Sallis, and Cavill (1998), it
may be more desirable to focus on promoting regular physical activity habits that will be retained
throughout life.
It will be necessary. therefore, to have a multicomponent approach to promotion where
theories compatible with behavior change are used to plan interventions that take into account
multiple mediators of physical activity habits (e.g., self efficacy) as well as social-ecological
determinants and moderators (e.g., socializing agents such as parents, peers. teachers and
moderators such as school, proximity to resources and access to programs).
Familv and Communitv Level Promotion
Sallis (1998) has suggested a variety of interventions of both a social and social-ecological
HalUre
(hat are consistent with the Centres for Disease Control and Prevention Guidelines (CDC:
1997). As he pointed out in his perspective on family and community interventions, the CDC
concensus may be the best resource for program planning in promoting physical activity for
young people. He summarizes several of the guidelines relevant to family and community level
i5
interventions.
These recommended guidelines will be attached to our final document for review as
appendices. Note that there are no evaluated, best practice interventions that can simply be
implemented. As noted by Sallis (1998) "those who plan community interventions for physical
activity must rely on their ability to apply multiple theories, the best available data, input from
members of the community, and creativity" (p. 156).
Pate, Mullis, Sallis, Trost, and Brown (in press) also note that in practice, communitybased interventions should be intense, prolonged, and engage all aspects of the community. They
argue that the programs should be theory-driven and based upon valid behavioral science
principles. Thus community leaders of all sorts should be involved (i.e., politicians,
neighborhood leaders, medical and public health leaders in promoting child health). Their
corresponding institutions should also be the settings that are involved in some form of
implementation of the intervention (i.e., home, school, medical, community, mass media, local
government).
Regarding home interventions, Pate et al (in press) recommend the involvement of family
members particularly for children. The purpose of family involvement is not only the reliance of
children on parents for transportation to physical activities. It is also the role they have to play in
(a) being positive role models by modifying their own behavior (increase activity) (b) providing a
home environment that facilitates physical activity and reduces inactivity, and in (c) providing
positive reinforcement when children maintain or improve their activity levels.
School Interventions
These interventions received attention in a number of the sources we examined and
reviewed. Once again, however, we refer the reader to the Centers for Disease Control and
Prevention guidelines (1997) because the guidelines were the outcome of one of the most recent
concensus processes and combine the input of experts. the scientific literature and the
creativity/objectivity of those involved in the concensus meeting. Pate et al (in-press) noted that
the guidelines encouraged schools to work with community-based programs as follows:
16
1.
Develop links with community resources and educate students, parents, staff about
available physical activity programs.
2.
Schools could make their facilities available for community-operated programs after
school and weekends to promote greater access and opportunities for participation.
3.
Coordination between school and community could be facilitiated by using community
experts/resources as part of the educational program (i.e., guest speakers) thereby
exposing students to novel expertise and linking the expert community resource person
and the community resource/program students and school educators. Schools could also
link with community-based public health agencies to promote local. provincial, or national
physical activity campaigns.
Health Professional Phvsician-Based Intervention
Pate et al (in press) recommend that health-care providers counsel adolescents about the
benefits of regular physical activity and should screen for youth "at risk" for inactivity. They
should provide counsel and appropriate referral. Further, physicians and other health-care
providers are recommended as community advocates in the promotion of physical activity
opportunities that are developmentally sound. These recommendations are also consistent with
those outlined in Durant and Hergenroeder (1994: Pediatric Exercise Science). In their article,
seven recommendations were made that cover advocacy, training, screening assessment, and
counseling by physicians who treat adolescents involved in physical activity. Their guidelines
suggest that when educating adolescents about their health and physical activity as a health
behavior, the physician will need to be aware of the social context in which the adolescent
implements the advice. Accordingly, the physician should counsel so that the adolescent builds
self-efficacy for exercising in that context. These authors also identify a number of barriers that
prevent health care providers from delivering effective counseling (e.g., lack of training in (a)
exercise prescription, (b) health promotion and counseling, (c) counseling protocols; lack of
standard counseling protocols; busy office practices; poor reimbursement for preventative health
care). These recommendations and barriers must be taken into account in any primary health care
17
provider intervention.
18
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