Hassan Soubhi | Université du Québec à Chicoutimi (original) (raw)
Papers by Hassan Soubhi
There is a famous quote from the movie Cool Hand Luke [1] when the prison warden says to Luke rig... more There is a famous quote from the movie Cool Hand Luke [1] when the prison warden says to Luke right after hitting him, " What we've got here is failure to communicate ; some men you just can't reach. " Aside from the entertaining drama, I keep two implications from this quotation: communication is more than information transfer, it is also about reach; and reach can be costly. A dictionary definition reveals several meanings for the word " reach " : stretch out; touch or grasp by stretching; arrive at; get in contact; and interestingly enough, " succeed in having an effect on " [2]. I lean toward the latter, simply because thinking of communication as exerting an influence offers a better chance of assessing that influence. Our goals must be smart and measurable. They must also consider local contexts. Communication is central in an interprofessional context. Problems arise when we treat communication mainly as an exchange of information and ignore all the subtle non-verbal signifiers: attitudes, body language, cultural norms, and institutional rules. Shannon and Weaver [3] offered a theory of communication as reliability in encoding and decoding information as a set of symbols. We usually conceive of communication as the transfer of a string of symbols with the assumption that the syntactic rules are known—we get the meaning if we can decode the string. This view is appealing. We see its usefulness in computers as they extend our minds every day. It becomes, however, particularly costly with specialization and the increased division of labour that is necessary for collective works. As it increases productivity, specialization also brings with it elaborate algorithms that only experts know. A higher level of energy must then be spent to encode and decode expert informa-tion—a cost that can be prohibitive in an interprofessional context, which calls for speed and efficiency in the integration and transfer of knowledge. So if interprofessional communication is more than information transfer, and if the division of labour increases both the productivity and the costs of communication, what can we do? How can we better understand interprofessional communication? First, we need to consider that an effective interprofessional group lowers the costs of communication. The human history of collective work is filled with successive attempts to reduce those costs and coordinate the exchange of energy—an important part of what makes or breaks collective work. For what do groups do in the real world? At a fundamental level, they exchange information and energy. In doing so, they establish connections between agents and objects: the connections can be physical (as in sharing the other end of the rope), symbolic (as in incentives), or mental (as in language and working memories in the brain). Group members not only exchange bits
Journal of Interprofessional Care, 2009
Despite the increasing prevalence of chronic conditions and multimorbidities, the essential attri... more Despite the increasing prevalence of chronic conditions and multimorbidities, the essential attributes of the structure and delivery of primary care continue to be
defi ned in terms of disease-specifi c approaches and acute conditions. Effective improvements will require alternative ways of thinking about chronic care design and practice. This essay argues for an ecosystemic understanding of chronic care
founded on a communal and a dynamic view of the response of the patient, family, and health professionals to chronic illness. The communal view highlights the cocreative nature of the response to illness and the need to integrate the
skills and resources of all the participants; what and how the participants learn in the course of the illness become central to chronic care. The dynamic view draws attention to the unfolding of illness management activities over time and to the
need to engage the illness at specifi c time points or recurring time intervals that have the potential for important change in the experience of the participants. Chronic care would then include design for community, with an emphasis on the
patient and family as necessary participants in the health care team. It would also include design for emergent learning and practice whereby health professionals go beyond standardization of care processes to develop new ways to
harness the participants’ imagination and learn from the changing experience of illness. Health professionals would also learn to cultivate trust, communal engagement, and openness to experimentation that facilitate collective learning,
and help sharpen the participants’ responsiveness to the emergent.
We introduce a primary care practice model for caring for patients with multimorbidity. Primary c... more We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires flexibility and ongoing
coordination, and it often must be tailored to individual circumstances. Such complex and flexible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other’s goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would define common
goals, cocreate care plans, and engage in reflective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a
mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding
these conditions, we can foster the development of collective learning and improve primary care for these patients.
The greatest resource for improving interprofessional learning and practice is the knowledge, wis... more The greatest resource for improving interprofessional learning and practice is the knowledge, wisdom, and energy of professionals who adapt to challenging situations in their everyday work. We call collective capability the ability of a group of professionals to balance two interdependent levels of
organization of practice: what professionals know and what they do collectively over time. Organizing what professionals know links the relational value – caring for patients – to the knowledge value of practice. Organizing what professionals do includes human and organizational factors that facilitate
collective work and learning: technical skills for care delivery, institutional support, and a complex mix of emotional, ethical and moral factors involved in social decision-making. Performance gaps can result from a lack of an integrated knowledge framework or from a disembodied knowledge that is not anchored in practice. Opportunities for continuous learning can be seized by documenting the source
of the performance gap, and providing the relevant resources to establish the balance between the organization of knowledge and the organization of work.
OBJECTIVE To provide a summary of evidence on the effectiveness of interventions to promote physi... more OBJECTIVE To provide a summary of evidence on the effectiveness of interventions to promote physical activity among patients affected by at least 1 chronic disease. The interventions studied were each targeted at a single risk factor. DATA SOURCES MEDLINE, CINAHL, and EMBASE were searched from 1966 to 2006 using 2 sets of search terms. First we searched using physical activity
BMC Family Practice, 2010
Background: Among the strategies used to reform primary care, the participation of nurses in prim... more Background: Among the strategies used to reform primary care, the participation of nurses in primary care practices appears to offer a promising avenue to better meet the needs of vulnerable patients. The present study explores the perceptions and expectations of patients with multimorbidity regarding nurses' presence in primary care practices. Methods: 18 primary (health) care patients with multimorbidity participated in semi-directed interviews, in order to explore their perceptions and expectations in regard to the involvement of nurses in primary care practices. Interviews were audio-recorded and transcribed. After reviewing the transcripts, the principal investigator and research assistants performed thematic analysis independently and reached consensus on the retained themes.
BMC Family Practice, 2010
Background: Among the strategies used to reform primary care, the participation of nurses in prim... more Background: Among the strategies used to reform primary care, the participation of nurses in primary care practices appears to offer a promising avenue to better meet the needs of vulnerable patients. The present study explores the perceptions and expectations of patients with multimorbidity regarding nurses' presence in primary care practices. Methods: 18 primary (health) care patients with multimorbidity participated in semi-directed interviews, in order to explore their perceptions and expectations in regard to the involvement of nurses in primary care practices. Interviews were audio-recorded and transcribed. After reviewing the transcripts, the principal investigator and research assistants performed thematic analysis independently and reached consensus on the retained themes.
The Annals of Family Medicine, 2010
We introduce a primary care practice model for caring for patients with multimorbidity. Primary c... more We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires fl exibility and ongoing coordination, and it often must be tailored to individual circumstances. Such complex and fl exible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other's goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would defi ne common goals, cocreate care plans, and engage in refl ective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients.
Health and Quality of Life Outcomes, 2007
The presence of multiple chronic conditions is associated with lower health related quality of li... more The presence of multiple chronic conditions is associated with lower health related quality of life (HRQOL). Disease severity also influences HRQOL. To analyse the effects of all possible combinations of single diseases along with their severity on HRQOL seems cumbersome. Grouping diseases and their severity in specific organ domains may facilitate the study of the complex relationship between multiple chronic conditions and HRQOL. The goal of this study was to analyse impaired organ domains that affect the most HRQOL of patients with multiple chronic conditions in primary care and their possible interactions.
Health Qual Life …, 2005
Measures of multimorbidity are often applied to source data, populations or outcomes outside the ... more Measures of multimorbidity are often applied to source data, populations or outcomes outside the scope of their original developmental work. As the development of a multimorbidity measure is influenced by the population and outcome used, these influences should be taken into account when selecting a multimorbidity index. The aim of this study was to compare the strength of the association of health-related quality of life (HRQOL) with three multimorbidity indices: the Cumulative Illness Rating Scale (CIRS), the Charlson index (Charlson) and the Functional Comorbidity Index (FCI). The first two indices were not developed in light of HRQOL.
Journal of Interprofessional Care, 2009
Reviews, 1996
Many people with chronic disease have more than one chronic condition, which is referred to as mu... more Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions for multimorbidity. To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. We searched MEDLINE, EMBASE, CINAHL, CAB Health, AMED, HealthStar, The Cochrane Central Register of Controlled Trials (CENTRAL), the EPOC Register and the Database of Abstracts of Reviews of Effectiveness (DARE), and the EPOC Register in April 2011. We considered randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series analyses (ITS) reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. The outcomes included any validated measure of physical or mental health, psychosocial status including quality of life outcomes, well-being, and measures of disability or functional status. We also included measures of patient and provider behaviour including measures of medication adherence, utilisation of health services, and acceptability of services and costs. Two review authors independently assessed studies for eligibility, extracted data, and assessed study quality. Meta-analysis of results was not possible so we carried out a narrative synthesis of the results from the included studies. Ten studies examining a range of complex interventions for patients with multimorbidity were identified. All were RCTs and there was low risk of bias. Two of the nine studies focused on specific co-morbidities. The remaining studies focused on multimorbidity, generally in older patients. All studies involved complex interventions with multiple elements. In six of the ten studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, the interventions were predominantly patient oriented. Overall the results were mixed with a trend towards improved prescribing and medication adherence. The results indicate that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors or functional difficulties in patients with co-morbid conditions or multimorbidity may be more effective. Cost data were limited with no economic analyses included, though the improvements in prescribing and risk factor management in some studies provided potentially significant cost savings. This review highlights the paucity of research into interventions to improve outcomes for multimorbidity with the focus to date being on co-morbid conditions or multimorbidity in older patients. The limited results suggest that interventions to date have had mixed effects but have shown a tendency to improve prescribing and medication adherence, particularly if interventions can be targeted at risk factors or specific functional difficulties in people with co-morbid conditions or multimorbidity. There is a need for clear definitions of participants, consideration of appropriate outcomes, and further pragmatic studies based in primary care settings.
Journal of Clinical Epidemiology, 2007
Canadian family physician Médecin de famille canadien, 2008
To provide a summary of evidence on the effectiveness of interventions to promote physical activi... more To provide a summary of evidence on the effectiveness of interventions to promote physical activity among patients affected by at least 1 chronic disease. The interventions studied were each targeted at a single risk factor. MEDLINE, CINAHL, and EMBASE were searched from 1966 to 2006 using 2 sets of search terms. First we searched using physical activity or physical fitness or exercise and health care or primary care or primary health care or family practice or medical office or physician's office and health promotion or health education or counselling. Then we used physical activity or exercise and diabetes or hyperlipidemia or hypertension or obesity or cardiovascular disease or pulmonary disease or risk factor or comorbidity and health promotion or health education or counselling or prescription. We chose randomized controlled trials or trials with a controlled quasi-experimental design that evaluated single risk factor interventions to promote physical activity among adult p...
There is a famous quote from the movie Cool Hand Luke [1] when the prison warden says to Luke rig... more There is a famous quote from the movie Cool Hand Luke [1] when the prison warden says to Luke right after hitting him, " What we've got here is failure to communicate ; some men you just can't reach. " Aside from the entertaining drama, I keep two implications from this quotation: communication is more than information transfer, it is also about reach; and reach can be costly. A dictionary definition reveals several meanings for the word " reach " : stretch out; touch or grasp by stretching; arrive at; get in contact; and interestingly enough, " succeed in having an effect on " [2]. I lean toward the latter, simply because thinking of communication as exerting an influence offers a better chance of assessing that influence. Our goals must be smart and measurable. They must also consider local contexts. Communication is central in an interprofessional context. Problems arise when we treat communication mainly as an exchange of information and ignore all the subtle non-verbal signifiers: attitudes, body language, cultural norms, and institutional rules. Shannon and Weaver [3] offered a theory of communication as reliability in encoding and decoding information as a set of symbols. We usually conceive of communication as the transfer of a string of symbols with the assumption that the syntactic rules are known—we get the meaning if we can decode the string. This view is appealing. We see its usefulness in computers as they extend our minds every day. It becomes, however, particularly costly with specialization and the increased division of labour that is necessary for collective works. As it increases productivity, specialization also brings with it elaborate algorithms that only experts know. A higher level of energy must then be spent to encode and decode expert informa-tion—a cost that can be prohibitive in an interprofessional context, which calls for speed and efficiency in the integration and transfer of knowledge. So if interprofessional communication is more than information transfer, and if the division of labour increases both the productivity and the costs of communication, what can we do? How can we better understand interprofessional communication? First, we need to consider that an effective interprofessional group lowers the costs of communication. The human history of collective work is filled with successive attempts to reduce those costs and coordinate the exchange of energy—an important part of what makes or breaks collective work. For what do groups do in the real world? At a fundamental level, they exchange information and energy. In doing so, they establish connections between agents and objects: the connections can be physical (as in sharing the other end of the rope), symbolic (as in incentives), or mental (as in language and working memories in the brain). Group members not only exchange bits
Journal of Interprofessional Care, 2009
Despite the increasing prevalence of chronic conditions and multimorbidities, the essential attri... more Despite the increasing prevalence of chronic conditions and multimorbidities, the essential attributes of the structure and delivery of primary care continue to be
defi ned in terms of disease-specifi c approaches and acute conditions. Effective improvements will require alternative ways of thinking about chronic care design and practice. This essay argues for an ecosystemic understanding of chronic care
founded on a communal and a dynamic view of the response of the patient, family, and health professionals to chronic illness. The communal view highlights the cocreative nature of the response to illness and the need to integrate the
skills and resources of all the participants; what and how the participants learn in the course of the illness become central to chronic care. The dynamic view draws attention to the unfolding of illness management activities over time and to the
need to engage the illness at specifi c time points or recurring time intervals that have the potential for important change in the experience of the participants. Chronic care would then include design for community, with an emphasis on the
patient and family as necessary participants in the health care team. It would also include design for emergent learning and practice whereby health professionals go beyond standardization of care processes to develop new ways to
harness the participants’ imagination and learn from the changing experience of illness. Health professionals would also learn to cultivate trust, communal engagement, and openness to experimentation that facilitate collective learning,
and help sharpen the participants’ responsiveness to the emergent.
We introduce a primary care practice model for caring for patients with multimorbidity. Primary c... more We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires flexibility and ongoing
coordination, and it often must be tailored to individual circumstances. Such complex and flexible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other’s goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would define common
goals, cocreate care plans, and engage in reflective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a
mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding
these conditions, we can foster the development of collective learning and improve primary care for these patients.
The greatest resource for improving interprofessional learning and practice is the knowledge, wis... more The greatest resource for improving interprofessional learning and practice is the knowledge, wisdom, and energy of professionals who adapt to challenging situations in their everyday work. We call collective capability the ability of a group of professionals to balance two interdependent levels of
organization of practice: what professionals know and what they do collectively over time. Organizing what professionals know links the relational value – caring for patients – to the knowledge value of practice. Organizing what professionals do includes human and organizational factors that facilitate
collective work and learning: technical skills for care delivery, institutional support, and a complex mix of emotional, ethical and moral factors involved in social decision-making. Performance gaps can result from a lack of an integrated knowledge framework or from a disembodied knowledge that is not anchored in practice. Opportunities for continuous learning can be seized by documenting the source
of the performance gap, and providing the relevant resources to establish the balance between the organization of knowledge and the organization of work.
OBJECTIVE To provide a summary of evidence on the effectiveness of interventions to promote physi... more OBJECTIVE To provide a summary of evidence on the effectiveness of interventions to promote physical activity among patients affected by at least 1 chronic disease. The interventions studied were each targeted at a single risk factor. DATA SOURCES MEDLINE, CINAHL, and EMBASE were searched from 1966 to 2006 using 2 sets of search terms. First we searched using physical activity
BMC Family Practice, 2010
Background: Among the strategies used to reform primary care, the participation of nurses in prim... more Background: Among the strategies used to reform primary care, the participation of nurses in primary care practices appears to offer a promising avenue to better meet the needs of vulnerable patients. The present study explores the perceptions and expectations of patients with multimorbidity regarding nurses' presence in primary care practices. Methods: 18 primary (health) care patients with multimorbidity participated in semi-directed interviews, in order to explore their perceptions and expectations in regard to the involvement of nurses in primary care practices. Interviews were audio-recorded and transcribed. After reviewing the transcripts, the principal investigator and research assistants performed thematic analysis independently and reached consensus on the retained themes.
BMC Family Practice, 2010
Background: Among the strategies used to reform primary care, the participation of nurses in prim... more Background: Among the strategies used to reform primary care, the participation of nurses in primary care practices appears to offer a promising avenue to better meet the needs of vulnerable patients. The present study explores the perceptions and expectations of patients with multimorbidity regarding nurses' presence in primary care practices. Methods: 18 primary (health) care patients with multimorbidity participated in semi-directed interviews, in order to explore their perceptions and expectations in regard to the involvement of nurses in primary care practices. Interviews were audio-recorded and transcribed. After reviewing the transcripts, the principal investigator and research assistants performed thematic analysis independently and reached consensus on the retained themes.
The Annals of Family Medicine, 2010
We introduce a primary care practice model for caring for patients with multimorbidity. Primary c... more We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires fl exibility and ongoing coordination, and it often must be tailored to individual circumstances. Such complex and fl exible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other's goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would defi ne common goals, cocreate care plans, and engage in refl ective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients.
Health and Quality of Life Outcomes, 2007
The presence of multiple chronic conditions is associated with lower health related quality of li... more The presence of multiple chronic conditions is associated with lower health related quality of life (HRQOL). Disease severity also influences HRQOL. To analyse the effects of all possible combinations of single diseases along with their severity on HRQOL seems cumbersome. Grouping diseases and their severity in specific organ domains may facilitate the study of the complex relationship between multiple chronic conditions and HRQOL. The goal of this study was to analyse impaired organ domains that affect the most HRQOL of patients with multiple chronic conditions in primary care and their possible interactions.
Health Qual Life …, 2005
Measures of multimorbidity are often applied to source data, populations or outcomes outside the ... more Measures of multimorbidity are often applied to source data, populations or outcomes outside the scope of their original developmental work. As the development of a multimorbidity measure is influenced by the population and outcome used, these influences should be taken into account when selecting a multimorbidity index. The aim of this study was to compare the strength of the association of health-related quality of life (HRQOL) with three multimorbidity indices: the Cumulative Illness Rating Scale (CIRS), the Charlson index (Charlson) and the Functional Comorbidity Index (FCI). The first two indices were not developed in light of HRQOL.
Journal of Interprofessional Care, 2009
Reviews, 1996
Many people with chronic disease have more than one chronic condition, which is referred to as mu... more Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions for multimorbidity. To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. We searched MEDLINE, EMBASE, CINAHL, CAB Health, AMED, HealthStar, The Cochrane Central Register of Controlled Trials (CENTRAL), the EPOC Register and the Database of Abstracts of Reviews of Effectiveness (DARE), and the EPOC Register in April 2011. We considered randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series analyses (ITS) reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. The outcomes included any validated measure of physical or mental health, psychosocial status including quality of life outcomes, well-being, and measures of disability or functional status. We also included measures of patient and provider behaviour including measures of medication adherence, utilisation of health services, and acceptability of services and costs. Two review authors independently assessed studies for eligibility, extracted data, and assessed study quality. Meta-analysis of results was not possible so we carried out a narrative synthesis of the results from the included studies. Ten studies examining a range of complex interventions for patients with multimorbidity were identified. All were RCTs and there was low risk of bias. Two of the nine studies focused on specific co-morbidities. The remaining studies focused on multimorbidity, generally in older patients. All studies involved complex interventions with multiple elements. In six of the ten studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, the interventions were predominantly patient oriented. Overall the results were mixed with a trend towards improved prescribing and medication adherence. The results indicate that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors or functional difficulties in patients with co-morbid conditions or multimorbidity may be more effective. Cost data were limited with no economic analyses included, though the improvements in prescribing and risk factor management in some studies provided potentially significant cost savings. This review highlights the paucity of research into interventions to improve outcomes for multimorbidity with the focus to date being on co-morbid conditions or multimorbidity in older patients. The limited results suggest that interventions to date have had mixed effects but have shown a tendency to improve prescribing and medication adherence, particularly if interventions can be targeted at risk factors or specific functional difficulties in people with co-morbid conditions or multimorbidity. There is a need for clear definitions of participants, consideration of appropriate outcomes, and further pragmatic studies based in primary care settings.
Journal of Clinical Epidemiology, 2007
Canadian family physician Médecin de famille canadien, 2008
To provide a summary of evidence on the effectiveness of interventions to promote physical activi... more To provide a summary of evidence on the effectiveness of interventions to promote physical activity among patients affected by at least 1 chronic disease. The interventions studied were each targeted at a single risk factor. MEDLINE, CINAHL, and EMBASE were searched from 1966 to 2006 using 2 sets of search terms. First we searched using physical activity or physical fitness or exercise and health care or primary care or primary health care or family practice or medical office or physician's office and health promotion or health education or counselling. Then we used physical activity or exercise and diabetes or hyperlipidemia or hypertension or obesity or cardiovascular disease or pulmonary disease or risk factor or comorbidity and health promotion or health education or counselling or prescription. We chose randomized controlled trials or trials with a controlled quasi-experimental design that evaluated single risk factor interventions to promote physical activity among adult p...