Skip to main content
Top
Published in: BMC Primary Care 1/2015

Open Access 01-12-2015 | Research article

“Keeping Moving”: factors associated with sedentary behaviour among older people recruited to an exercise promotion trial in general practice

Authors: Ruth Heseltine, Dawn A. Skelton, Denise Kendrick, Richard W. Morris, Mark Griffin, Deborah Haworth, Tahir Masud, Steve Iliffe

Published in: BMC Primary Care | Issue 1/2015

Login to get access

Abstract

Background

Sedentary behaviour is detrimental to health, even in those who achieve recommended levels of physical activity. Efforts to increase physical activity in older people so that they reach beneficial levels have been disappointing. Reducing sedentary behaviour may improve health and be less demanding of older people, but it is not clear how to achieve this. We explored the characteristics of sedentary older people enrolled into an exercise promotion trial to gain insights about those who were sedentary but wanted to increase activity.

Method

Participants in the ProAct65+ trial (2009–2013) were categorised as sedentary or not using a self-report questionnaire. Demographic data, health status, self-rated function and physical test performance were examined for each group. 1104 participants aged 65 & over were included in the secondary analysis of trial data from older people recruited via general practice. Results were analysed using logistic regression with stepwise backward elimination.

Results

Three hundred eighty seven (35 %) of the study sample were characterised as sedentary. The likelihood of being categorised as sedentary increased with an abnormal BMI (<18.5 or >25 kg/m2) (Odds Ratio 1.740, CI 1.248–2.425), ever smoking (OR 1.420, CI 1.042–1.934) and with every additional medication prescribed (OR 1.069, CI 1.016–1.124). Participants reporting better self-rated physical health (SF-12) were less likely to be sedentary; (OR 0.961, 0.936–0.987). Participants’ sedentary behaviour was not associated with gender, age, income, education, falls, functional fitness, quality of life or number of co-morbidities.

Conclusion

Some sedentary older adults will respond positively to an invitation to join an exercise study. Those who did so in this study had poor self-rated health, abnormal BMI, a history of smoking, and multiple medication use, and are therefore likely to benefit from an exercise intervention.

Trial registration

ISRCTN reference: ISRCTN43453770
Literature
1.
go back to reference Sedentary Behaviour Research N. Letter to the editor: standardized use of the terms “sedentary” and “sedentary behaviours”. Appl Physiol Nutr Metab. 2012;37(3):540–2. Sedentary Behaviour Research N. Letter to the editor: standardized use of the terms “sedentary” and “sedentary behaviours”. Appl Physiol Nutr Metab. 2012;37(3):540–2.
2.
go back to reference de Rezende LFM, Rey-Lopez JP, Matsudo VKR, do Carmo Luiz O. Sedentary behavior and health outcomes among older adults: a systematic review. BMC Public Health. 2014;14(1):333.PubMedPubMedCentral de Rezende LFM, Rey-Lopez JP, Matsudo VKR, do Carmo Luiz O. Sedentary behavior and health outcomes among older adults: a systematic review. BMC Public Health. 2014;14(1):333.PubMedPubMedCentral
3.
go back to reference Grontved A, Hu FB. Television viewing and risk of type 2 diabetes, cardiovascular disease, and all-cause mortality: a meta-analysis. Jama. 2011;305(23):2448–55.PubMedPubMedCentral Grontved A, Hu FB. Television viewing and risk of type 2 diabetes, cardiovascular disease, and all-cause mortality: a meta-analysis. Jama. 2011;305(23):2448–55.PubMedPubMedCentral
4.
go back to reference Department of Health U. Start Active, Stay Active: A report on physical activity for health from the four home countries’ Chief Medical Officers. 2011. Department of Health U. Start Active, Stay Active: A report on physical activity for health from the four home countries’ Chief Medical Officers. 2011.
5.
go back to reference Health BHFCfPAa. Sedentary Behaviour evidence briefing. 2012. Health BHFCfPAa. Sedentary Behaviour evidence briefing. 2012.
6.
go back to reference Owen N, Healy GN, Matthews CE, Dunstan DW. Too much sitting: the population health science of sedentary behavior. Exer Sport Sci Rev. 2010;38(3):105–13. Owen N, Healy GN, Matthews CE, Dunstan DW. Too much sitting: the population health science of sedentary behavior. Exer Sport Sci Rev. 2010;38(3):105–13.
7.
go back to reference Davis MG, Fox KR, Hillsdon M, Sharp DJ, Coulson JC, Thompson JL. Objectively measured physical activity in a diverse sample of older urban UK adults. Med Sci Sports Exerc. 2011;43(4):647–54.PubMed Davis MG, Fox KR, Hillsdon M, Sharp DJ, Coulson JC, Thompson JL. Objectively measured physical activity in a diverse sample of older urban UK adults. Med Sci Sports Exerc. 2011;43(4):647–54.PubMed
8.
go back to reference Bennie JA, Chau JY, van der Ploeg HP, Stamatakis E, Do A, Bauman A. The prevalence and correlates of sitting in European adults—a comparison of 32 Eurobarometer-participating countries. Int. 2013;10:107. Bennie JA, Chau JY, van der Ploeg HP, Stamatakis E, Do A, Bauman A. The prevalence and correlates of sitting in European adults—a comparison of 32 Eurobarometer-participating countries. Int. 2013;10:107.
9.
go back to reference Bankoski A, Harris TB, McClain JJ, Brychta RJ, Caserotti P, Chen KY, et al. Sedentary activity associated with metabolic syndrome independent of physical activity. Diabetes Care. 2011;34(2):497–503.PubMedPubMedCentral Bankoski A, Harris TB, McClain JJ, Brychta RJ, Caserotti P, Chen KY, et al. Sedentary activity associated with metabolic syndrome independent of physical activity. Diabetes Care. 2011;34(2):497–503.PubMedPubMedCentral
10.
go back to reference Gardiner PA, Healy GN, Eakin EG, Clark BK, Dunstan DW, Shaw JE, et al. Associations between television viewing time and overall sitting time with the metabolic syndrome in older men and women: the Australian Diabetes, Obesity and Lifestyle study. J Am Geriatr Soc. 2011;59(5):788–96.PubMed Gardiner PA, Healy GN, Eakin EG, Clark BK, Dunstan DW, Shaw JE, et al. Associations between television viewing time and overall sitting time with the metabolic syndrome in older men and women: the Australian Diabetes, Obesity and Lifestyle study. J Am Geriatr Soc. 2011;59(5):788–96.PubMed
11.
go back to reference Gennuso KP, Gangnon RE, Matthews CE, Thraen-Borowski KM, Colbert LH. Sedentary behavior, physical activity, and markers of health in older adults. Med Sci Sports Exerc. 2013;45(8):1493–500.PubMed Gennuso KP, Gangnon RE, Matthews CE, Thraen-Borowski KM, Colbert LH. Sedentary behavior, physical activity, and markers of health in older adults. Med Sci Sports Exerc. 2013;45(8):1493–500.PubMed
12.
go back to reference van der Berg JD, Bosma H, Caserotti P, Eiriksdottir G, Arnardottir NY, Martin KR, Brychta RJ, Chen KY, Sveinsson T, Johannsson E, Launer LJ, Gudnason V, Jonsson PV, Stehouwer CDA, Harris TB, Koster A. Midlife determinants assoicated with sedentary behaviour in old age. Med Sci Sports Exer. 2014; 46(7):1359–65. van der Berg JD, Bosma H, Caserotti P, Eiriksdottir G, Arnardottir NY, Martin KR, Brychta RJ, Chen KY, Sveinsson T, Johannsson E, Launer LJ, Gudnason V, Jonsson PV, Stehouwer CDA, Harris TB, Koster A. Midlife determinants assoicated with sedentary behaviour in old age. Med Sci Sports Exer. 2014; 46(7):1359–65.
13.
go back to reference Seguin R, Lamonte M, Tinker L, Liu J, Woods N, Michael YL, et al. Sedentary Behavior and Physical Function Decline in Older Women: Findings from the Women’s Health Initiative. J Aging Res. 2012;2012:271589.PubMedPubMedCentral Seguin R, Lamonte M, Tinker L, Liu J, Woods N, Michael YL, et al. Sedentary Behavior and Physical Function Decline in Older Women: Findings from the Women’s Health Initiative. J Aging Res. 2012;2012:271589.PubMedPubMedCentral
14.
go back to reference Chastin SFM, Mandrichenko O, Helbostadt JL, Skelton DA. Associations between objectively-measured sedentary behaviour and physical activity with bone mineral density in adults and older adults, the NHANES study. Bone. 2014;64:254–62.PubMed Chastin SFM, Mandrichenko O, Helbostadt JL, Skelton DA. Associations between objectively-measured sedentary behaviour and physical activity with bone mineral density in adults and older adults, the NHANES study. Bone. 2014;64:254–62.PubMed
15.
go back to reference Katzmarzyk PT, Church TS, Craig CL, Bouchard C. Sitting time and mortality from all causes, cardiovascular disease, and cancer. Med Sci Sports Exerc. 2009;41(5):998–1005.PubMed Katzmarzyk PT, Church TS, Craig CL, Bouchard C. Sitting time and mortality from all causes, cardiovascular disease, and cancer. Med Sci Sports Exerc. 2009;41(5):998–1005.PubMed
16.
go back to reference Kaplan MS, Huguet N, Newsom JT, McFarland BH. Characteristics of physically inactive older adults with arthritis: results of a population-based study. Prev Med. 2003;37(1):61–7.PubMed Kaplan MS, Huguet N, Newsom JT, McFarland BH. Characteristics of physically inactive older adults with arthritis: results of a population-based study. Prev Med. 2003;37(1):61–7.PubMed
17.
go back to reference Dogra S, Stathokostas L. Sedentary behavior and physical activity are independent predictors of successful aging in middle-aged and older adults. J Aging Res. 2012;2012:190654.PubMedPubMedCentral Dogra S, Stathokostas L. Sedentary behavior and physical activity are independent predictors of successful aging in middle-aged and older adults. J Aging Res. 2012;2012:190654.PubMedPubMedCentral
18.
go back to reference Strath SJ, Schwartz AM, Cashin SE. Ambulatory physical activity profiles of older adults. J Aging Phys Activity. 2009;17(1):46–56. Strath SJ, Schwartz AM, Cashin SE. Ambulatory physical activity profiles of older adults. J Aging Phys Activity. 2009;17(1):46–56.
19.
go back to reference Kikuchi H, Inoue S, Sugiyama T, Owen N, Oka K, Shimomitsu T. Correlates of prolonged television viewing time in older Japanese men and women. BMC Public Health. 2013;13:213.PubMedPubMedCentral Kikuchi H, Inoue S, Sugiyama T, Owen N, Oka K, Shimomitsu T. Correlates of prolonged television viewing time in older Japanese men and women. BMC Public Health. 2013;13:213.PubMedPubMedCentral
20.
go back to reference Inoue S, Sugiyama T, Takamiya T, Oka K, Owen N, Shimomitsu T. Television viewing time is associated with overweight/obesity among older adults, independent of meeting physical activity and health guidelines. J Epidemiol. 2012;22(1):50–6.PubMedPubMedCentral Inoue S, Sugiyama T, Takamiya T, Oka K, Owen N, Shimomitsu T. Television viewing time is associated with overweight/obesity among older adults, independent of meeting physical activity and health guidelines. J Epidemiol. 2012;22(1):50–6.PubMedPubMedCentral
21.
go back to reference Chastin SFM, Fitzpatrick N, Andrews M, DiCroce N. Determinants of sedentary behavior, motivation, barriers and strategies to reduce sitting time in older women: a qualitative investigation. Int J Environ Res Public Health. 2014;11(1):773–91.PubMedPubMedCentral Chastin SFM, Fitzpatrick N, Andrews M, DiCroce N. Determinants of sedentary behavior, motivation, barriers and strategies to reduce sitting time in older women: a qualitative investigation. Int J Environ Res Public Health. 2014;11(1):773–91.PubMedPubMedCentral
22.
go back to reference Arnardottir NY, Koster A, Van Domelen DR, Brychta RJ, Caserotti P, Eiriksdottir G, et al. Objective measurements of daily physical activity patterns and sedentary behaviour in older adults: Age, Gene/Environment Susceptibility-Reykjavik Study. Age Ageing. 2013;42(2):222–9.PubMed Arnardottir NY, Koster A, Van Domelen DR, Brychta RJ, Caserotti P, Eiriksdottir G, et al. Objective measurements of daily physical activity patterns and sedentary behaviour in older adults: Age, Gene/Environment Susceptibility-Reykjavik Study. Age Ageing. 2013;42(2):222–9.PubMed
23.
go back to reference Harvey JA, Chastin SFM, Skelton DA. Prevalence of sedentary behaviour in older adults: a systematic review. Int J Environ Res Public Health. 2013;10:6645–61.PubMedPubMedCentral Harvey JA, Chastin SFM, Skelton DA. Prevalence of sedentary behaviour in older adults: a systematic review. Int J Environ Res Public Health. 2013;10:6645–61.PubMedPubMedCentral
24.
go back to reference Stamatakis E, Davis M, Stathi A, Hamer M. Associations between multiple indicators of objectively-measured and self-reported sedentary behaviour and cardiometabolic risk in older adults. Prev Med. 2012;54(1):82–7.PubMed Stamatakis E, Davis M, Stathi A, Hamer M. Associations between multiple indicators of objectively-measured and self-reported sedentary behaviour and cardiometabolic risk in older adults. Prev Med. 2012;54(1):82–7.PubMed
25.
go back to reference Matthews CE, Chen KY, Freedson PS, Buchowski MS, Beech BM, Pate RR, et al. Amount of time spent in sedentary behaviors in the United States, 2003–2004. Am J Epidemiol. 2008;167(7):875–81.PubMedPubMedCentral Matthews CE, Chen KY, Freedson PS, Buchowski MS, Beech BM, Pate RR, et al. Amount of time spent in sedentary behaviors in the United States, 2003–2004. Am J Epidemiol. 2008;167(7):875–81.PubMedPubMedCentral
26.
go back to reference van der Ploeg HP, Chey T, Korda RJ, Banks E, Bauman A. Sitting time and all-cause mortality risk in 222 497 Australian adults. Arch Intern Med. 2012;172(6):494–500.PubMed van der Ploeg HP, Chey T, Korda RJ, Banks E, Bauman A. Sitting time and all-cause mortality risk in 222 497 Australian adults. Arch Intern Med. 2012;172(6):494–500.PubMed
27.
go back to reference Tudor-Locke CE, Myers AM. Challenges and opportunities for measuring physical activity in sedentary adults. Sports Med. 2001;31(2):91–100.PubMed Tudor-Locke CE, Myers AM. Challenges and opportunities for measuring physical activity in sedentary adults. Sports Med. 2001;31(2):91–100.PubMed
28.
go back to reference Espana-Romero V, Golubic R, Martin KR, Hardy R, Ekelund U, Kuh D, et al. Comparison of the EPIC Physical Activity Questionnaire with combined heart rate and movement sensing in a nationally representative sample of older British adults. PLoS One. 2014;9(2):e87085.PubMedPubMedCentral Espana-Romero V, Golubic R, Martin KR, Hardy R, Ekelund U, Kuh D, et al. Comparison of the EPIC Physical Activity Questionnaire with combined heart rate and movement sensing in a nationally representative sample of older British adults. PLoS One. 2014;9(2):e87085.PubMedPubMedCentral
29.
go back to reference van Uffelen JGZ, Heesch KC, Hill RL, Brown WJ. A qualitative study of older adults’ responses to sitting-time questions: do we get the information we want? BMC Public Health. 2011;11:458.PubMedPubMedCentral van Uffelen JGZ, Heesch KC, Hill RL, Brown WJ. A qualitative study of older adults’ responses to sitting-time questions: do we get the information we want? BMC Public Health. 2011;11:458.PubMedPubMedCentral
30.
go back to reference Visser M, Koster A. Development of a questionnaire to assess sedentary time in older persons—a comparitive study using accelerometry. BMC Geriatr. 2013;13(80):1471–2318. Visser M, Koster A. Development of a questionnaire to assess sedentary time in older persons—a comparitive study using accelerometry. BMC Geriatr. 2013;13(80):1471–2318.
31.
go back to reference Buman MP, Hekler EB, Haskell WL, Pruitt L, Conway TL, Cain KL, et al. Objective light-intensity physical activity associations with rated health in older adults. Am J Epidemiol. 2010;172(10):1155–65.PubMedPubMedCentral Buman MP, Hekler EB, Haskell WL, Pruitt L, Conway TL, Cain KL, et al. Objective light-intensity physical activity associations with rated health in older adults. Am J Epidemiol. 2010;172(10):1155–65.PubMedPubMedCentral
32.
go back to reference Pate RR, O'Neill JR, Lobelo F. The evolving definition of “sedentary”. Exerc Sport Sci Rev. 2008;36(4):173–8.PubMed Pate RR, O'Neill JR, Lobelo F. The evolving definition of “sedentary”. Exerc Sport Sci Rev. 2008;36(4):173–8.PubMed
33.
go back to reference Healy GN, Dunstan DW, Salmon J, Cerin E, Shaw JE, Zimmet PZ, et al. Breaks in sedentary time: beneficial associations with metabolic risk. Diabetes Care. 2008;31(4):661–6.PubMed Healy GN, Dunstan DW, Salmon J, Cerin E, Shaw JE, Zimmet PZ, et al. Breaks in sedentary time: beneficial associations with metabolic risk. Diabetes Care. 2008;31(4):661–6.PubMed
34.
go back to reference Fitzsimons CF, Kirk A, Baker G, Michie F, Kane C, Mutrie N. Using an individualised consultation and activPAL feedback to reduce sedentary time in older Scottish adults: results of a feasibility and pilot study. Prev Med. 2013;57(5):718–20.PubMed Fitzsimons CF, Kirk A, Baker G, Michie F, Kane C, Mutrie N. Using an individualised consultation and activPAL feedback to reduce sedentary time in older Scottish adults: results of a feasibility and pilot study. Prev Med. 2013;57(5):718–20.PubMed
35.
go back to reference Gardiner PA, Eakin EG, Healy GN, Owen N. Feasibility of reducing older adults’ sedentary time. Am J Prev Med. 2011;41(2):174–7.PubMed Gardiner PA, Eakin EG, Healy GN, Owen N. Feasibility of reducing older adults’ sedentary time. Am J Prev Med. 2011;41(2):174–7.PubMed
36.
go back to reference Magistro D, Liubicich ME, Candela F, Ciairano S. Effect of ecological walking training in sedentary elderly people: act on aging study. Gerontologist. 2014;54(4):611–23.PubMed Magistro D, Liubicich ME, Candela F, Ciairano S. Effect of ecological walking training in sedentary elderly people: act on aging study. Gerontologist. 2014;54(4):611–23.PubMed
37.
go back to reference Stevens Z, Barlow C, Kendrick D, Masud T, Skelton DA, Dinan-Young S. Effectiveness of general practice-based physical activity promotion for older adults: systematic review. Prim Health Care Res Dev. 2014;15(2):190–201.PubMed Stevens Z, Barlow C, Kendrick D, Masud T, Skelton DA, Dinan-Young S. Effectiveness of general practice-based physical activity promotion for older adults: systematic review. Prim Health Care Res Dev. 2014;15(2):190–201.PubMed
38.
go back to reference Iliffe S, Kendrick D, Morris R, Skelton D, Gage H, Dinan S, et al. Multi-centre cluster randomised trial comparing a community group exercise programme with home based exercise with usual care for people aged 65 and over in primary care: protocol of the ProAct 65+ trial. Trials. 2010;11(1):6.PubMedPubMedCentral Iliffe S, Kendrick D, Morris R, Skelton D, Gage H, Dinan S, et al. Multi-centre cluster randomised trial comparing a community group exercise programme with home based exercise with usual care for people aged 65 and over in primary care: protocol of the ProAct 65+ trial. Trials. 2010;11(1):6.PubMedPubMedCentral
39.
go back to reference Iliffe S, Kendrick D, Morris R, Masud T, Gage H, Skelton D, et al. Multicentre cluster randomised trial comparing a community group exercise programme and home-based exercise with usual care for people aged 65 years and over in primary care. Health Technol Assess. 2014;18(49):1–105.PubMedPubMedCentral Iliffe S, Kendrick D, Morris R, Masud T, Gage H, Skelton D, et al. Multicentre cluster randomised trial comparing a community group exercise programme and home-based exercise with usual care for people aged 65 years and over in primary care. Health Technol Assess. 2014;18(49):1–105.PubMedPubMedCentral
40.
go back to reference Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav. 1997;38(1):21–37.PubMed Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav. 1997;38(1):21–37.PubMed
41.
go back to reference DeSalvo KB, Bloser N, Reynolds K, He J, Muntner P. Mortality prediction with a single general self-rated health question. A meta-analysis. J Gen Intern Med. 2006;21(3):267–75.PubMedPubMedCentral DeSalvo KB, Bloser N, Reynolds K, He J, Muntner P. Mortality prediction with a single general self-rated health question. A meta-analysis. J Gen Intern Med. 2006;21(3):267–75.PubMedPubMedCentral
42.
go back to reference Rikli RE, Jones CJ. Functional fitness normative scores for community-residing older adults aged 60–94. J Aging Phys Act. 1999;7:162–81. Rikli RE, Jones CJ. Functional fitness normative scores for community-residing older adults aged 60–94. J Aging Phys Act. 1999;7:162–81.
43.
go back to reference Bohannon RW. Reference values for the timed up and go test: a descriptive meta-analysis. J Geriatr Phys Ther. 2006;29(2):64–8.PubMed Bohannon RW. Reference values for the timed up and go test: a descriptive meta-analysis. J Geriatr Phys Ther. 2006;29(2):64–8.PubMed
44.
go back to reference Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a new clinical measure of balance. J Gerontol. 1990;45(6):M192–7.PubMed Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a new clinical measure of balance. J Gerontol. 1990;45(6):M192–7.PubMed
45.
go back to reference Jenkinson C, Chandola T, Coulter A, Bruster S. An assessment of the construct validity of the SF-12 summary scores across ethnic groups. J Public Health Med. 2001;23(3):187–94.PubMed Jenkinson C, Chandola T, Coulter A, Bruster S. An assessment of the construct validity of the SF-12 summary scores across ethnic groups. J Public Health Med. 2001;23(3):187–94.PubMed
46.
go back to reference Mols F, Pelle AJ, Kupper N. Normative data of the SF-12 health survey with validation using postmyocardial infarction patients in the Dutch population. Qual Life Res. 2009;18(4):403–14.PubMed Mols F, Pelle AJ, Kupper N. Normative data of the SF-12 health survey with validation using postmyocardial infarction patients in the Dutch population. Qual Life Res. 2009;18(4):403–14.PubMed
47.
go back to reference Reeder BA, Chad KE, Harrison EL, Ashworth NL, Sheppard MS, Fisher KL, et al. Saskatoon in motion: class- versus home-based exercise intervention for older adults with chronic health conditions. J Phys Act Health. 2008;5(1):74–87.PubMed Reeder BA, Chad KE, Harrison EL, Ashworth NL, Sheppard MS, Fisher KL, et al. Saskatoon in motion: class- versus home-based exercise intervention for older adults with chronic health conditions. J Phys Act Health. 2008;5(1):74–87.PubMed
48.
go back to reference Bowling A, Iliffe S. Psychological approach to successful ageing predicts future quality of life in older adults. Health Qual Life Outcomes. 2011;9:13.PubMedPubMedCentral Bowling A, Iliffe S. Psychological approach to successful ageing predicts future quality of life in older adults. Health Qual Life Outcomes. 2011;9:13.PubMedPubMedCentral
49.
go back to reference Yardley L, Donovan-Hall M, Francis K, Todd C. Attitudes and beliefs that predict older people’s intention to undertake strength and balance training. J Gerontol B Psychol Sci Soc Sci. 2007;62(2):119–25. Yardley L, Donovan-Hall M, Francis K, Todd C. Attitudes and beliefs that predict older people’s intention to undertake strength and balance training. J Gerontol B Psychol Sci Soc Sci. 2007;62(2):119–25.
Metadata
Title
“Keeping Moving”: factors associated with sedentary behaviour among older people recruited to an exercise promotion trial in general practice
Authors
Ruth Heseltine
Dawn A. Skelton
Denise Kendrick
Richard W. Morris
Mark Griffin
Deborah Haworth
Tahir Masud
Steve Iliffe
Publication date
01-12-2015
Publisher
BioMed Central
Published in
BMC Primary Care / Issue 1/2015
Electronic ISSN: 2731-4553
DOI
https://doi.org/10.1186/s12875-015-0284-z

Other articles of this Issue 1/2015

BMC Primary Care 1/2015 Go to the issue