How starting a patient education, fitness program can improve health
Walk with a Doc (WWaD) is a simple model: physicians, allied health providers and fitness professionals deliver a high-yield discussion on an important health topic and then walk side by side with their patients and clients.
The program was created to inspire participants to regularly exercise as a means to improve health. What makes WWaD unique is its combination of health teaching with regular exercise in a year-round, informal setting that makes participants comfortable interacting with healthcare providers and the health and wellness team. Without the usual formality of the medical office, patients witness their physicians practicing what they preach.
Cardiac and pulmonary diseases are just some of the many ailments that can significantly improve with regular exercise. In fact, even light exercise can reduce mortality and extend life expectancy, while inactivity is associated with at least a twofold increase in the risk for coronary events. Exercise has been shown to improve not only cardiovascular disease risk factors, but also many other aspects of health including glycemic control, cancer, obesity, smoking cessation, brain function and cognition, and psychological state.
Unfortunately, motivation to get started with exercise is often lacking for many patients. Hard work is needed to address this growing problem.
WWaD started with the work of David Sabgir, MD, in 2006 and through grassroots efforts spread from his practice in Columbus, Ohio, to dozens of other sites in the Ohio area. Over the next several years, the program spread throughout the country and now has chapters around the world in Canada, India, United Arab Emirates, and Russia, with more starting each month. In all, there are more than 100 active WWaD programs nationwide.
In this report, we characterize the first WWaD program established in Colorado and demonstrate the program’s challenges along with solutions to maintain sustainability and growth. We describe the logistics of the program after reviewing the challenges so that it may be easily replicated.
Transportation and location
WWaD in Denver chose centrally located parks near several forms of public transportation. The parks chosen are pedestrian- and bicycle-friendly, and are connected by major roads with sidewalks with several nearby bus routes. Use of government-subsidized transportation vehicles is encouraged when available to participants. All parks have ample free parking. Smaller public parks were chosen rather than larger parks to enable some of the less-capable participants to find the meeting place without excessive difficulty.
Four steps to motivating patients
Many people who are not accustomed to regular exercise find exercise to be a chore rather than a fun way to stay healthy. WWaD used several methods to motivate, incentivize, and inspire people to exercise more.
First, WWaD organizers solicited local beverage companies and coffee shops to provide free refreshments and hot coffee.
Second, donations from local sponsors were requested from an athletic shoe company, a nutritional supplement company, and a granola company. Each month, to inspire people to return, previous participants were randomly selected to win gift cards and gift baskets from these sponsor companies.
Third, every new participant received an athletic shirt and pedometer to keep track of steps. Fourth, every participant receives a name tag at every walk. Participants are introduced to each other via their name tag and by volunteer staff who help make connections. The goal is to inspire people to meet each other and thereby motivate them to do better at each WWaD event, to return, and perhaps to form groups to walk on their own outside of WWaD events.
Since organizers demonstrate a commitment to exercising year-round in all weather, participants feel comfortable that this program consistently meets. Finally, children, strollers, and pets were always welcome.
Different fitness abilities
Many participants under the care of physicians are sicker and sometimes require oxygen and assistive walking devices. As a result, many of these participants were worried that they wouldn’t keep up with the group, fall, get sick, or felt they just couldn’t walk the distance.
To counter these issues, the program was widely advertised not just to the public, but also in doctors’ offices around Denver. Assistive devices and medical walkers were encouraged, and an ambulance company donated time to be at all of the events. The participants were encouraged to walk to the best of their ability and to stop or rest when needed. At the start of the walk, the wide spectrum of participant abilities naturally sorted into smaller walking groups.
WWaD volunteers were instructed to walk in various parts of the line to ensure the safety of participants and to provide gentle encouragement. The fitness trainers, nutritionists, and exercise physiologists were encouraged to offer advice and engage patients in their particular fields of expertise. Finally, the comfort of walking with healthcare professionals eliminated or reduced the worry of an adverse outcome and added a layer of safety for many patients.
Patients would rather exercise alone
Besides the obvious group dynamic that encourages people to do more,, before the start of each walk, a local Tai Chi expert leads a 5-10 minute warm up. Tai Chi can improve health, especially among the elderly.
In addition, a talk was conducted by a local expert physician speaker on a topic in his or her field of practice. Then, when walking side by side with the participants, he or she answers questions. Another benefit of the program was the free blood pressure checks offered to all participants. These added activities, education, and screening were driving factors for patients to come to and frequent the program rather than walk on their own.
Professionals in any medical or fitness field are worried about their liability if problems occur or if adverse outcomes result from a program they run. At WWaD, all organizers purchase inexpensive liability insurance offered through the national program headquarters. In Denver, every participant signed a waiver of liability. Finally, a volunteer ambulance was retained on site for any potential emergencies.
Engaging healthcare providers and fitness professionals
One of the main attractions of the WWaD program is the opportunity for participants to directly interact with healthcare and fitness professionals. At every walk, organizers strive to have at least two doctors present (usual turnout was eight).
All levels of allied health professionals, including one or more registered dieticians, volunteered their time at every walk event. Local fitness coaches and trainers, physical therapists, and exercise physiologists were involved in every walk and were integral in working with participants to inspire walking effort.
The healthcare and fitness professionals were retained through an understanding of the goal of health promotion, support of a community cause, and the natural ability of such programs to foster trust and alliances resulting in new clients, patients, or customers.
Recruitment and promotion for WWaD is a critical component of its success. Flyers were created to house four months worth of events in trimesters, to keep costs low and allow for maximum impact. The benefits of the free giveaways, refreshments, blood pressure checks, and physician discussion were highlighted on all materials. E-mail addresses of all participants are collected and an email one week prior to each WWaD event is sent.
Social media promotion is of critical importance. Simply having a presence on Facebook or Meetup.com was not enough by itself. Regular promotion through sharing links, wall posts, photos, and contests run to “Like Us on Facebook” were used to further amplify promotion efforts. Through the generosity of our sponsors, we were able to offer items such as free athletic shoes and walking guidebooks through our Facebook page. If one person “likes” WWaD on Facebook, especially as part of a contest, this action is shared with that person’s friends, which markedly increases advertising reach.
Through Meetup.com, organizers create events, such as a WWaD event, and then participation is open to the entire Meetup.com community. Through regular postings and updates, the Meetup.com group added nearly 300 participants to the WWaD program in Denver.
Maintaining financial and sponsor support
Keeping a program like WWaD going takes coordinated efforts in fundraising and sponsor retention. Local businesses, including a beverage distributor for water, a supermarket for fresh fruit, and financial support from several local medical practices, have kept this program running at no cost to participants. The financial support allowed for the purchase of T-shirts, production of flyers and outdoor advertising, amd pedometers, and provided the incentives for patients to continue to return to WWaD.
In exchange for the support offered, sponsors’ logos appeared on all printed flyers, billboards, and T-shirts and received exposure at WWaD programs. Billboard/outdoor advertising companies were approached and provided free or low-cost advertising in exchange for recognition at the events. A sponsorship brochure was developed to illustrate the benefits of the program for companies.
In the Denver area more than 1,500 people have participated in WWaD since its inception in May 2010, and the program continues to grow. The program started with 15 participants at an event, and this number increased to an average of 25 new participants per walk, with at least 55 repeat participants at each event. The program has also inspired six other doctors in the state to start WWaD programs.
After approval by our institution’s review board, some participants volunteered to be studied informally through surveys (completed at the end of each walk). Participants rated their peak walk effort based on the modified Borg scale. Exercise efforts outside of WWaD were gathered. Quality of life was assessed using the Healthcare Quality of Life survey. As a test of learned concepts from the physician expert lecture, a series of four multiple-choice questions created by the physician speaker were administered. Two weeks after the event, a follow-up survey was administered via secure email to assess knowledge retention using the same questions.
Of the 168 participants with fully completed surveys, the mean age was 56.4 years, with a range of 18-79 years. The majority enrolled were female (74%). Most enrolled participants came multiple times: 48% completed two or more walks, 27% completed three or more walks, 14% completed four or more walks, and 11% completed five or more walks. The perceived shortness of breath score decreased 0.4 points on the Borg Scale by the second walk. Thirty-five subjects in the entire cohort reported a decrease of about two mental health days from the first walk to the third walk.
Statistical analysis could only be completed when more than one walk was attended, and because this was an informal analysis, many gaps in the data exist and firm conclusions are not possible.
In testing for medical knowledge retention, scores two weeks later were similar to scores the day of the walk for each participant’s first three walks. As such there was no loss of knowledge, suggesting retention of the health information given.
Growth of the patient-provider relationship
Many participants were able to see their efforts as transformative. As patient health status improved, physician organizers of this effort were seen as “health coaches” and would often have their patients challenging themselves and reporting back regularly on their goals and successes at routine office follow ups. Anecdotally, many organizers have been invited to participate in 10K walks and races with their patients.
The most powerful result reported by organizers was the comfort and closeness patients felt with their physician co-participants. Patients were often humbled by the desire of their own physicians to improve the health of participants and were able to see a more human side of physicians that was seldom seen in the office.
This “breaking down” of barriers significantly strengthened the relationship of patient to physician for many participants. For several physician participants, this relationship strengthening was refreshing because it reminded them of the reasons they sought a career in medicine.
The benefits for organizers of WWaD have been many. First, major local and national media outlets have reported on the WWaD effort and helped the program grow. Among the healthcare professionals who dedicated time to this effort, their practices have seen many new patients as a result of these efforts. Patients and the community have embraced the effort, which has resulted in appointments to local and regional governmental organization leadership positions. The growth of our local efforts has also enabled the organizers to help replicate efforts statewide, each with similar success. Finally, the satisfaction gained from watching participants become healthier and fitter while embracing exercise as medicine has been the most rewarding of all.
Getting involved is easy
WWaD is a novel program that was developed to help make regular exercise in a community setting fun, enriching, and self-sustaining. At WWaD, not only are doctors prescribing exercise, they are actively engaged in leading behavioral change and setting the example with the help of a range of allied health and fitness professionals. Through informal patient encounters at WWaD events, the doctor-patient relationship is strengthened and mutual respect continues to empower patients to improve their lives through regular physical activity.
Community fitness programs such as WWaD have been demonstrated to reduce disease and are cost-effective. Our program is also designed to serve as a catalyst for patients to exercise regularly outside of the program. Promoting physical activity in a group has a motivating effect on people to do more. WWaD has enabled people to increase fitness activity.
WWaD, like all community-based exercise programs, faces many challenges. Through careful planning, many of these challenges can be overcome, and the sustainability of a quality program can be maintained. WWaD in Colorado has demonstrated growth and sustainability and inspired participants to use social networks to further improve healthful living. WWaD narrows the gap between patients and the entire healthcare team including physicians, nurses, and fitness professionals. It creates empowered, knowledgeable patients, who in turn may help to reduce health care expenditures. Further research and expanded programs are indicated to assess the magnitude of these effects on larger populations.
WWaD has the power to promote health in a local community. The concept is simple, the program is easy to implement, and the national WWaD team along with regional leaders are eager to help get you started.