Increasing Access to Physical Activity Opportunities for Patients: A Review

Abstract

Physical activity has been shown to improve health outcomes, decrease risk of medical comorbidities, and improve longevity. Despite these known benefits, most individuals do not meet the recommended national exercise guidelines for physical activity. This paper identifies individual and community-level factors impacting engagement in physical activity, thus focusing on solutions to address common barriers to exercise and optimize diversity, equity, and inclusion initiatives for physical activity. Afterward, several cases within one large academic institution and its affiliates illustrate recent endeavors to improve access to physical activity and highlight future opportunities for growth in all communities.

“Thoughtful community planning should be emphasized with avenues to promote PA in mind.”

Introduction

Physical activity (PA) positively impacts health. Research consistently shows that PA improves cardiovascular health, ¹ treats metabolic conditions such as diabetes, ² and reduces the risk of many cancers. ³ There is also substantial evidence suggesting PA favorably affects mental health by mitigating depression, anxiety, psychosis, and neurodevelopmental disorders such as attention-deficit/hyperactivity disorder (ADHD). ⁴ Physical activity has even been shown to support longevity through improved cognition and lower the risk of dementia.^5-7

Despite research demonstrating the positive impacts of PA, the majority of the U.S. population does not meet the recommended guidelines for physical activity. ⁸ At the same time, 70% of American deaths as well as 75% of the nation’s annual health care costs are due to preventable chronic disease such as heart disease and stroke, which can be attenuated through PA. ⁹ National guidelines recommend at least 150 minutes of moderate or 75 minutes of vigorous aerobic physical activity in addition to two or more days of resistance or strength training per week for most adults. ¹⁰ The United States Preventive Services Task Force (USPSTF) Guidelines for Physical Activity, in particular, recommends moderate to vigorous PA for at least 90-180 minutes per week. ¹¹ Supporting these guidelines, studies have demonstrated a link between increasing PA and decreased risk of mortality and morbidity.^10,12-15 This underscores the importance of increasing patients’ access to PA to help people live better and longer lives.

This paper explores strategies for enhancing patient access to PA given its substantial positive and comprehensive impact. At the individual level, it will first examine behavioral approaches that encourage sustained engagement in PA. From a system-level approach, it will then discuss community initiatives aimed at increasing access to PA, with a particular focus on how these initiatives have been implemented at Stanford Health Care and affiliated institutions, focusing on programs such as the Cardinal Free Musculoskeletal Clinic, Stanford Lifestyle Medicine, initiatives at the Palo Alto Department of Veterans Affairs (PAVA), and diversity, equity, and inclusion endeavors. By highlighting these examples, we elucidate possible ways to increase access to PA while proposing ways to develop longitudinal systems that integrate PA into clinical practice.

Methods

A literature review was conducted in PubMed with the following search terms: “physical activity,” “exercise,” “individual,” “community,” “equity,” “psychology,” “diversity,” and “inclusion.” Titles and abstracts were screened for appropriateness and relevance in addressing individual and community-level barriers to physical activity, with a focus on articles with proposed interventions targeting physical and/or psychological approaches to increasing patient access to physical activity. A total of 30 articles were included in the final review, ranging from publication dates 1998-2024.

Individual-Level Approaches to Increasing Patient Access to Physical Activity

An individual’s pursuit of regular activity depends on a holistic intersection between physical, cognitive, and psychological health. From a physical health standpoint, the presence of common medical comorbidities, such as cardiovascular disease, pulmonary disease, diabetes, and osteoarthritis can greatly impact general cardiorespiratory fitness, endurance, and exercise tolerance, which can limit PA.^16-18 Mental health can facilitate PA but also provide isolated barriers to regular PA. Depression is linked to higher rates of cardiovascular disease and disease-related mortality, affected by factors such as increased sedentary behavior, higher overall body mass index (BMI), and increased caloric consumption,^19-21 but it also leads to metabolic and hormonal imbalances that impact energy levels and activity.^22,23 Similarly, generalized anxiety disorder can be associated with increased caloric intake and higher BMIs, yet is also associated with increased energy expenditure, which may lead to feelings of exhaustion and fatigue that prohibit PA.^24,25 These can lead to a vicious cycle where mental and physical conditions worsen and limit PA.

To address these physical and psychological barriers to PA, comprehensive strategies to target improvements in PA have been identified. The Physical Activity Guidelines for Americans (PAG) recommends behavioral interventions including emphasis on peer support, camaraderie, and use of technology, such as wearables, to improve one’s ability to track measurable exercise data and set specific goals. ²⁶ Goals should be simplified and achievable using the well-published S.M.A.R.T criteria, which stands for specific, measurable, achievable, realistic, and timed. This criteria is often used to identify or brainstorm opportunities for growth based on desired behavioral change. ²⁷ When setting goals to increase PA, an individual can use the S.M.A.R.T criteria in conjunction with current technology and peer support to create actionable goals for PA, including metrics on type of activity, duration, intensity, and timeline to achieve goals. ²⁸ Highlighting the role of creating S.M.A.R.T goals to increase PA, a recent randomized-controlled trial showed that a goal-setting program had a significant positive impact on endurance, agility, sprinting, jumping, grip strength, attitude towards exercise, and feelings of behavioral control. ²⁹ Another study found that an emphasis on goal-setting and accountability through peer support led to higher rates of adherence to PA. ³⁰

Another method to increase PA is through motivational interviewing (MI). MI is a commonly used strategy to promote behavioral change by identifying values and ideals that resonate with an individual’s vision of his or her current self and ideal future self. ³¹ The hallmarks of MI include an identified target area for possible change, the use of collaborative and empathetic listening to understand the individual’s thoughts toward the target area, and empowering individuals to create their own rationales to inspire change. ³¹ MI resonates with principles of acceptance and commitment therapy (ACT), which involves processing ideas for behavioral change with improved psychological flexibility driven by internal values. Studies support the use of MI and ACT to increase individual’s participation in PA. For instance, one single-blind randomized-controlled trial of 30 adults with a recent hip fracture showed the positive impact of MI specifically on physical activity. In this study, 16 adults, upon discharge from rehabilitation into the community, were randomized to an intervention group, in which they received eight weekly sessions of MI, while the remaining 14 adults were in a control group. The study found that adults in the intervention group who received MI had a significantly greater number of steps taken per day, walked for longer periods of time, and were more confident about walking with less fear of falls than those in the non-motivational interviewing control group. This highlights how MI can promote PA and lead to downstream health benefits. ³² One recent systematic review and meta-analysis found small to moderate increases in PA in six separate randomized-controlled trials with ACT interventions, suggesting that this approach can also increase individual participation in PA. ³³

Inspired by positive psychology, adopting and employing a P.E.R.M.A framework can increase individual’s participation in PA. P.E.R.M.A stands for Positive Emotion, Engagement, Relationships, Meaning, and Accomplishments and is a strength-based approach to affecting behavioral change. The P.E.R.M.A framework has been devised as a way to measure different contributions of positivity toward an individual’s overall well-being by emphasizing feelings of happiness and purpose, and it serves as a marker of psychological resilience. In a study of 1741 college nursing students in China, lower levels of PA participation were associated with low levels of reported well-being via the P.E.R.M.A framework. Students with moderate to high levels of overall well-being were not observed within the group of low PA participation. ³⁴ Thus, optimization of a positive attitude and psychological resilience can inspire an individual to further pursue PA.

Finally, it is important to encourage all forms of physical exercise. ACSM encourages PA in all possible permutations, regardless of level of intensity. In partnership with ACSM, the American College of Lifestyle Medicine (ACLM) also echoes these same pillars on PA in all forms, via aspects such as the Exercise is Medicine^™ movement. ³⁵ This movement involves formal prescriptions for patients to pursue physical activity. An example of this formal prescription is via the ACSM’s Exercise is Medicine™ worksheet. This worksheet illustrates examples of moderate to vigorous activity and allows individuals to outline the frequency, intensity, and timing of aerobic activity and muscle strength training per week. ³⁶ Thus, exercise is made more concrete and becomes a measurable outcome per week. In addition, ACSM released an “Rx for Health” series that provides specific recommendations for guiding exercise in persons with various medical comorbidities, such as congestive heart failure, chronic obstructive pulmonary disorder, and osteoarthritis, who may face obstacles to regular engagement in activity. ³⁷ Lastly, the United States Department of Health and Human Services created the “Move Your Way” campaign to promote activity for individuals of all ages Office of Disease Prevention and Health Promotion. This campaign includes interactive tools, videos, and worksheets to engage individuals and families on finding ways to stay active and promote PA by promoting personal interests or hobbies. ³⁸

The USPSTF, in its recommendation on healthy diet and physical activity counseling, echoes similar behavioral counseling measures such as MI and P.E.R.M.A, but provides a more concrete backbone for setting PA goals, including moderate to vigorous PA for at least 90-180 minutes per week and participation with in-person or virtual behavioral counseling sessions to help individuals remain on track with their identified goals. ¹¹ Individuals can achieve these benchmarks or set personalized benchmarks through S.M.A.R.T goal-setting, in addition to use of ACT.

Furthermore, factors inherent to the individual can impact participation in PA. Although social factors like community engagement can promote PA, other social factors including age, gender, socioeconomic status, housing status, and disability status can create barriers around access to safe, regular PA. Strategies to improve PA in lower socioeconomic status groups include focusing on group-based activities, which tend to longitudinally improve PA. ³⁹ Optimizing approach to PA for communities by understanding cultural, faith-based, or societal norms can improve PA when linked to values of the community. To improve access to people with varying levels of education, educational materials on different types of PA can be provided in-print via short sentences and simple words, including easy-to-reference images, and offered in different languages. ⁴⁰ Health care professionals can also ensure PA is discussed at routine health care maintenance screenings, discussing free or available spaces for exercise in the community or local virtual or in-person exercise groups that may operate at discounted prices. ⁴¹

System-Level Approaches to Improving Physical Activity

Promoting PA also requires system-level approaches. A variety of local and national level community initiatives at Stanford University and the affiliated PAVA have improved access to general PA in a longitudinal manner.

Cardinal Free Musculoskeletal Medicine Clinic

The Cardinal Free Musculoskeletal Medicine Clinic serves as a vital health care resource for people living in underserved areas in San Mateo County, California (CA) for over 20 years. Among its specialized services, the Musculoskeletal (MSK) Specialty Clinic addresses non-operative orthopedic conditions for this vulnerable population. Operating on Sundays with a first-come, first-served model, the clinic provides immediate, no-cost medical attention while bridging patients to long-term care. A critical component of its success lies in its commitment to culturally competent care, which includes in-person interpreters for the most common languages spoken in the region. This ensures patients not only understand their treatment plans but feel respected and empowered, fostering trust and adherence to care recommendations.

This clinic increases patient access to PA by providing free radiology services for musculoskeletal imaging including radiographs, magnetic resonance imaging (MRI), and computed topography (CT) scans through Stanford Hospital to address possible injuries that may impact an individual’s ability to partake in PA. Additionally, the MSK Clinic has a partnership with Agile Physical Therapy (PT), a local PT clinic in Palo Alto, CA, which offers patients up to four free physical therapy sessions. These sessions empower individuals to partake in PA through tailored exercise programs designed to enhance mobility, reduce pain, and support long-term self-management. By integrating physical therapy referrals with education on physical activity, the clinic fosters sustainable lifestyle changes that extend beyond immediate care. In addition, at each patient appointment at the Cardinal Free MSK Clinic, patients are asked about their current activity level and given recommendations on exercise resources within the local community. This comprehensive approach not only addresses acute musculoskeletal issues, but also reduces the risk of chronic complications to improve patients’ quality of life.

The Cardinal Free MSK Clinic’s innovative model exemplifies how free clinics can address health care disparities while promoting PA as both a treatment and preventive measure against disability and medical comorbidities. Notably, it is one of the few MSK-specific free clinics in the United States, where over 1000 free clinics exist, but only a handful provide specialized musculoskeletal care.^42,43 This rarity underscores its significance, particularly in communities disproportionately burdened by barriers to care. By leveraging a volunteer network of physicians, medical students, and community partners, the clinic demonstrates the feasibility of community-driven care models. Its culturally tailored, patient-centered services highlight the importance of addressing both clinical and social determinants of health.

The clinic’s success serves as a potential framework for integrating specialty care and PA promotion within underserved communities. By overcoming common challenges—such as limited resources, sustaining community partnerships, and volunteer recruitment—the Cardinal Free MSK Clinic showcases a scalable model. Its approach holds the potential to inspire similar initiatives nationwide, reducing the long-term burden of chronic musculoskeletal conditions and expanding access to physical activity education. This vision aligns with broader efforts to address health inequities and improve population health through innovative, cost-effective solutions.

Stanford Lifestyle Medicine Program

Stanford Lifestyle Medicine (SLM) is a multidisciplinary group founded by Michael Fredericson, MD and Doug Noordsy, MD whose goal is to make healthy living accessible and achievable for all, regardless of background or circumstance. ⁴⁴ To accomplish this goal, SLM asks lifestyle medicine experts to produce content, teach, conduct research, and attend conferences and local events to educate about the seven pillars of lifestyle medicine: Movement and Exercise, Healthful Nutrition, Restorative Sleep, Stress Management, Social Engagement, Cognitive Enhancement, and Gratitude and Purpose. ⁴⁵

Within the realm of Movement and Exercise, SLM has put on regular events to teach the community about the benefits of PA. SLM has hosted in-person events to educate others on the benefits of PA, both to describe how to avoid injury and to integrate more daily movement. At a recent community event, SLM gave a seminar centered on how to prevent injury through proper form during movement and highlighted the benefits of short bursts of PA throughout the day, especially after meals, to better one’s health.

SLM has also produced numerous research articles and blog posts. In particular, SLM chronicles over 30 blog posts on relevant engaging topics, in just the movement and exercise space alone, providing actionable engaging tips to incorporate more exercise into people’s daily lives. ⁴⁵ The unique component of these tips is that they provide practical suggestions that individuals can implement into their lives.

In more academic settings, SLM has been a center for research in PA as well. There have been recent articles published by SLM and their members that discuss supplementation and physical performance as well as its relation to cognition and healthy aging, among other topics.^46,47

Additionally, SLM focuses on grassroots educational endeavors through collaboration with local Boys’ and Girls’ Clubs to reach young adults. SLM has also developed an education curriculum of high school and undergraduate level coursework that teaches students about lifestyle medicine to help individuals and communities.

Overall, the SLM group highlights how programs can spread knowledge about the benefits of PA and other elements of lifestyle medicine via a multimodal education-based approach in an achievable, approachable, cost-effective and reproducible way to engage with a broad audience.

Initiatives for Physical Activity at the Palo Alto Veterans Affairs

The PAVA is a one of the largest VA’s in the country with access to many resources and specialty services, including a polytrauma rehabilitation unit/program with a formal polytrauma transitional rehabilitation program. ⁴⁸ The focus of this polytrauma unit/rehabilitation program is to lead rehabilitation services for veterans or active-duty service members with brain injury and/or multiple concomitant injuries, helping them return to their daily lives as independently as possible. ⁴⁸ The PAVA is also a formal site for specialized spinal cord injury (SCI) care, with a specific SCI center that opened in 1974 to provide specialty services for veterans suffering from traumatic or non-traumatic SCI and multiple sclerosis. ⁴⁹

With these abundant resources and unified vision, the PAVA has a formal adaptive sports clinic run by physical medicine and rehabilitation (PM&R) physicians in conjunction with recreational therapists/therapy staff to encourage PA in veterans with disabilities. The PAVA has the highest number of recreational therapists of any VA in the country to promote ongoing fitness and activity in the veteran population. Veterans are referred to the adaptive sports clinic by recreational therapists, with adaptive sports team meetings occurring between PM&R physicians and physical therapists weekly. The VA also hosts a variety of national level recurring events, such as the National Veterans Wheelchair Games and the National Veterans Golden Age Games. ⁵⁰

To provide comprehensive veteran rehabilitation, including physical fitness, a new 24-hour wellness center was opened at the PAVA in 2021 to improve veteran and staff access to exercise. The wellness center is a modern, accessible three-story fitness pavilion with two large fitness/weight rooms, one yoga/dance studio, a large mezzanine-level indoor track, one full indoor basketball court, and a pool. Formal activities including weekly basketball, volleyball, pickleball (including adaptive pickleball), wheelchair rugby, and aerobic dance classes, thus highlighting inclusive forms of PA for individuals of all ages and abilities. Related, the PAVA offers different types of yoga sessions every weekday, including chair yoga, yoga for women veterans, mat yoga, yoga for chronic pain, and trauma-sensitive chair yoga, via its formal yoga/dance studio. There is also standing, seated, or wheelchair tai chi weekly with in-person and virtual options for a one-hour, guided session. Similarly, standing, seated, or wheelchair qi gong, a form of meditation through body movements and breathing control, is hosted with in-person and virtual options weekly for a one-hour, guided session.

Additionally, there is a hypertension education clinic hosted by the PAVA which focuses on a comprehensive approach to decreasing blood pressure by focusing on medications, diet, weight management, and physical activity. ⁵¹

In addition to the unique offerings of the PAVA, there are also several nationwide VA initiatives that are prominent within this health system. The VA MOVE! Clinic was started in 2006 as a nationwide endeavor to promote weight loss and PA among veterans. Criteria for enrollment include veterans with a BMI greater than or equal to 25. The hallmark feature of the MOVE! Program is a comprehensive lifestyle medicine practice, focusing on optimizing diet/nutrition, building upon positive psychology and healthy behavioral strategies, and encouraging PA with the goal of achieving at least a >5% weight loss. The intersection of these strategies to promote weight loss can occur via in-person MOVE! Clinic appointments at the VA, but with the COVID-19 pandemic, the MOVE! Program expanded to virtual care using telehealth services, which has been shown to be just as efficacious as in-person visits at promoting weight loss. ⁵² The MOVE! Program has led to at least a 5% decrease in weight, usually seen after six months, for 20%–25% of participants. ⁵³

The MOVE! Program’s particular focus on activity is achieving 150-300 minutes of PA per week, which can be tracked via cellular phone, tablets, or mobile apps. Participants receive daily education and can share their weight or health data with their care coordinators, who are primary points of contact to help veterans discuss behavioral changes to promote and maintain weight loss. Currently, over 35 000 veterans are enrolled in the MOVE! Program via their local VA’s or via telehealth services. ⁵⁰ The PAVA participates in the MOVE! Program with regular referrals coming from primary care physicians and specialists. At the PAVA, there are opportunities for veterans to participate in an orientation for the program, which is a 90-minute session offered on the first and third Wednesdays of each month.

In sum, the PAVA serves as a model system for the delivery of comprehensive lifestyle medicine with a robust offering of resources to increase PA. ⁵⁰

Individualizing Physical Activity Intervention

It is vital to contextualize individuals within their unique psychosocial context as social determinants of health influence access to and engagement in PA. Programs that offer culturally relevant exercise options, provide childcare services, and maintain flexible scheduling have demonstrated improved community participation rates and reduced health inequities. Thoughtful community planning should be emphasized with avenues to promote PA in mind. By building new or transforming established public infrastructure, communities can create inclusive spaces that encourage daily movement and support healthier lifestyles for all residents. Research suggests making communities more walkable with street lighting can promote a higher sense of safety and increase odds of engaging in more physical activity. ⁵⁴ This can make communities safer and more inviting, particularly for populations that may face unique barriers to exercise, such as older adults or individuals living in underserved areas that may not have access to gyms.

Investing in physical education (PE) in school curriculums can also help increase access to physical activity. In educational settings, PE programs play a critical role in fostering early habits of PA. Initiatives that increase the frequency of PE classes, provide comprehensive staff training, and ensure access to necessary equipment have been shown to significantly elevate activity levels among children. These effects are particularly pronounced in underserved communities, where extracurricular opportunities for PA may be limited. By embedding structured, inclusive PE programs into the school curriculum, however, educators can help mitigate disparities in access to exercise and promote lifelong health benefits for students.

Ultimately, fostering environments and supporting programs that support equitable access to exercise is a critical step in advancing public health and achieving long-term wellness outcomes for all.

Conclusion

Though physical activity has numerous comprehensive health benefits, both individual and systems-based factors can decrease regular participation in PA. Addressing barriers at the individual and communal level through a multifaceted approach, bridging optimization of physical health, psychological factors, and equitable access to activity, can improve participation in physical activity over a lifetime.