How Can and Do Australian Doctors Promote Physical Activity?

26, 866–873 (1997) PM970226

PREVENTIVE MEDICINE ARTICLE NO.

How Can and Do Australian Doctors Promote Physical Activity?1 Fiona C. L. Bull, Ph.D., M.Sc.,*,2 Elise C. C. Schipper, M.A.,* Konrad Jamrozik, M.B.B.S., D.Phil., FAFPHM,† and Brian A. Blanksby, Ph.D., M.Sc., Dip.Ed.* *Department of Human Movement and †Department of Public Health, University of Western Australia, Nedlands, Western Australia 6907, Australia

Background. Physical inactivity is recognized as an important public health issue. Yet little is known about doctors’ knowledge, attitude, skills, and resources specifically relating to the promotion of physical activity. Our survey assessed the current practice, perceived desirable practice, confidence, and barriers related to the promotion of physical activity in family practice. Methods. A questionnaire was developed and distributed to all 1,228 family practitioners in Perth, Western Australia. Results. We received a 71% response (n = 789). Family practitioners are most likely to recommend walking to sedentary adults to improve fitness and they are aware of the major barriers to patients participating in physical activity. Doctors are less confident at providing specific advice on exercise and may require further skills, knowledge, and experience. Although they promote exercise to patients through verbal advice in the consultation, few use written materials or referral systems. Conclusions. There are significant differences between self-reports of current practice and perceived desirable practice in the promotion of physical activity by doctors. Future strategies need to address the self-efficacy of family physicians and involve resources of proven effectiveness. The potential of referral systems for supporting efforts to increase physical activity by Australians should be explored. © 1997 Academic Press

Key Words: physical activity; family practice; survey; health education; self-efficacy. INTRODUCTION

The benefits of exercise are now well established, and these include a lower all-cause mortality, a reduc1 The authors are grateful for the financial support from the Western Australian Health Promotion Foundation (Healthway) and the National Heart Foundation (Western Australia). 2 To whom correspondence and reprint requests should be addressed at Department of Public Health, The University of Western Australia, Nedlands, Western Australia 6907, Australia. Fax: 09 380 1039.

tion in the risk of cardiovascular disease, and a positive effect on mood and well being [1–4]. Recent research has established the positive health-related benefits of participation in physical activity of moderate intensity [1]. These findings have led to amendments to the recommendations on physical activity from the National Institutes of Health, the Centers for Disease Control, and the American College of Sports Medicine. Specifically it is now recommended that all adults accumulate at least 30 min or more of physical activity of moderate intensity on most, or preferably all, days of the week [5]. This recommendation has also been adopted in Australia and the United Kingdom. In each country specific goals have been set for the reduction in the prevalence of physical inactivity. In Australia the aim is to reduce the proportion of male and female adults reporting no physical activity in the previous 2 weeks from 27% in 1989 to 20% by 1995 and 15% by the Year 2000 [6]. In the United States, the objective in Healthy People 2000 is to reduce the prevalence of sedentary male and female adults to no more than 15% [7]. Data from 1991 reveal 28% of American males and 31% of American females report doing no leisure-time physical activity within the previous month [8]. Given the established benefits of participation in moderate exercise and the prevalence of sedentary lifestyles, physical inactivity is now recognized as an important public health issue [1,6,9]. Family physicians (FPs) hold an unique position in terms of access to and influence with patients regarding health promotion and disease prevention. Approximately 83% of the Australian adult population visits a doctor at least once a year and doctors are seen by the public as a credible and preferred source of information [10–15]. The FP’s role in health promotion and specifically the promotion of physical activity is now the focus of much attention. Indeed, in both the United States and Australia there are recommendations that FPs should increase the frequency of assessment and counseling on physical activity. The Objectives for the Year 2000 state ‘‘Increase to at least 65% the proportion of primary care providers who assess and counsel their patients regarding the frequency, duration, type and

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HOW CAN AND DO FAMILY PHYSICIANS PROMOTE PHYSICAL ACTIVITY?

intensity of each patient’s physical activity practices as part of a thorough evaluation and treatment program’’ [7]. In Australia intermediate targets such as this have not yet been set, but the desired outcome in terms of a reduction in sedentary lifestyles has been defined. General practice has already been the focus of other health promotion strategies aimed at changing aspects of lifestyle, most notably in the area of cardiovascular risk reduction, cancer screening, and immunization [16–24]. While a number of studies in family practice have included physical activity as part of a multiple risk factor intervention, until recently few studies have focused solely on the promotion of physical activity [25]. Similarly, although there have been many surveys of health promotion in family practice [15,26–29], little is known about doctors’ knowledge, attitude, skills, and resources relating specifically to the promotion of physical activity. We conducted a postal survey of all FPs in Perth, the capital city of Western Australia (WA), to assess the following: current practice and perceived desirable practice in the use of various strategies for the promotion of physical activity, details and type of activity recommended, confidence of the doctor in advising patients on exercise, and knowledge of the barriers to patients increasing their participation in physical activity and their own participation in physical activity. Since individual doctors were asked only about their present pattern of practice, or about the pattern of practice they felt was desirable, we obtained an unbiased estimate of the size and nature of the gap between these two standards as they obtain among the entire primary care medical workforce serving a large population. Along with the data collected on factors facilitating or retarding doctors giving increased emphasis to the promotion of physical activity, our results provide a sound basis for planning initiatives that should result in a larger proportion of patients being encouraged by their FPs to become more active. METHOD

In April 1994 we conducted a postal survey of all 1,228 FPs serving Perth, the capital city of WA, and the neighboring city of Bunbury, the largest regional center in WA (population 1.2 million). We developed two questionnaires to enable assessment of and comparison between current practice (A) and perceived desirable practice (B) in the area of the promotion of physical activity by FPs. Questionnaire A contained items phrased ‘‘How often do you . . ?’’ while questionnaire B contained equivalent items phrased ‘‘How often should . . . ?’’ In order to avoid response bias concerning current practice, a given doctor received only questionnaire A or B. The questionnaire items addressed the following areas: the use of various strategies for the promotion of

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exercise, confidence in advising patients on exercise (self-efficacy), the details and type of physical activity recommended by the FP and the FP’s knowledge of the barriers to participation by patients in physical activity. What methods were being used, and what methods should be used, for the promotion of exercise in family practice were of particular practical interest. Doctors were asked to indicate the frequency of use of verbal advice, of written material either in the consultation or in the waiting room, of videos and of referral systems to specialist personnel, fitness centers, or other staff in the practice. Examples of specialist personnel include graduates in human movement science, physical education, and physiotherapy. The responses to these items were on a 5-point Likert scale ranging from ‘‘almost never’’ to ‘‘almost always’’ (questionnaire A) and ‘‘strongly disagree’’ to ‘‘strongly agree’’ (questionnaire B). One additional open-ended item assessed to which staff doctors might refer patients. Two items, common to questionnaire A and B, assessed the FP’s self-efficacy in providing both general and specific advice on exercise. These items were scored on a Likert scale ranging from ‘‘strongly agree’’ to ‘‘strongly disagree.’’ One item asked the doctor to report which type of exercise would (questionnaire A) or should (questionnaire B) be recommended ‘‘as a starting point for an otherwise healthy, sedentary adult to improve fitness.’’ The doctors were asked to chose one activity from a list of five types of exercise: vigorous exercise (‘‘exercise that makes you breathe harder or puff and pant’’), less vigorous exercise (‘‘exercise that does not make you breathe harder or puff and pant’’), physical activities apart from exercise (e.g., housework, heavy gardening), increased walking as part of daily activities (e.g., walking as a form of transport), and walking specifically for fitness. An additional item asked whether details of the desirable frequency, intensity, and duration of exercise were given to patients. We also wanted to know whether FPs were familiar with the common barriers to participation in exercise. Doctors were presented with a list of barriers and asked to indicate ‘‘in their opinion’’ how likely each barrier was to prevent a patient becoming more active. Again, a 5-point Likert scale was used ranging from ‘‘very unlikely to affect’’ to ‘‘very likely to affect.’’ Finally, both questionnaires included demographic questions including age and sex of the physician, size and location of the practice, years in family practice, number of patients seen per week, and the proportion of patients from a non-English-speaking background. In addition both questionnaires contained items on the role of the family practitioner in screening for, and recording of, physical inactivity and in discussing the benefits and programs of physical activity; on the types of patients to whom exercise was recommended; and on the barriers to the promotion of physical activity in

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BULL ET AL. TABLE 1 Age and Sex of Respondents ø35

Age categories (years)

n

Sex Male (n 4 545) Female (n 4 240) Total

99 94 193

ù56

36–45

46–55

Total

%

n

%

n

%

n

%

n

%

51 49 25

173 96 269

64 36 35

140 34 174

81 20 22

130 14 144

90 10 19

542 238 780

70 30 100

Note. Sex and age are significantly linked (x2 4 72.8, df 4 3, P < 0.0001).

family practice. The latter data and full details of the development and pilot work for the questionnaire have been published previously [30]. One questionnaire was posted to each doctor with a covering letter and reply-paid envelope. Care was taken to ensure that all physicians from the same practice received the same version of the questionnaire (A or B), but questionnaires were allocated to particular practices at random. (Using this distribution protocol 613 and 615 questionnaires were sent out for questionnaires A and B, respectively). Doctors were offered the chance to win a prize (complimentary golf tickets) as an incentive for early response, namely, return of a completed questionnaire within 2 weeks. Nonrespondents were sent up to two reminder letters and a further copy of the questionnaire at intervals of 21 days. The initial analysis assessed comparability of respondents to the different questionnaires in terms of age, sex, years in practice, and type of practice. In subsequent analyses x2 tests were used first to compare current practice with perceived desirable practice, and second, to look at differences between responses according to characteristics of the doctor. The protocol for the study was approved by the Committee for Human Rights of the University of Western Australia. RESULTS

A total of 789 valid questionnaires were returned, giving a corrected response of 71% after doctors no longer in family practice were removed from the denominator. The returns were evenly distributed across type of questionnaire (Questionnaire A, n 4 392; Questionnaire B, n 4 397) and localities. There were no significant differences across age, sex, years in general practice, and postgraduate qualification between the respondents to questionnaire A and the respondents to questionnaire B. A breakdown of the total respondents, by age and sex of the FPs, is given in Table 1. The group of nonresponding FPs was analyzed by age, sex, and postgraduate qualification (n 4 220). Using the Medical Directory of Australia (1993 edition), we found information on 175 nonresponders whose mean age (44 years, SD 4 11) and sex ratio (73% male) were not significantly different from those of the doctors who completed a questionnaire.

Doctors were asked about various methods of advising patients on exercise. Questionnaire A asked doctors ‘‘How often do you use . . .’’ and questionnaire B asked doctors ‘‘How often should you use . . . .’’ The results are shown in Fig. 1 and Table 2. There were significant differences between current practice and perceived desirable practice on the frequency of use of written information both in the consultation and in the waiting room, use of videos, and use of referral systems, but very little difference in regard to giving verbal advice during the consultation. Almost half (47%) of the doctors identified referral to a qualified (certified) fitness professional as desirable practice, with lower support for referral to a fitness center or to other staff within the practice. Despite this modest support, there was a very marked difference between desirable and selfreported actual practice in these areas. Table 3 presents the results on self-efficacy for all respondents and by sex of FP. The analysis revealed significant differences between general advice and specific advice and between males and females. Both male and female doctors feel more confident giving general compared with specific advice on exercise (males, x2 4 51.7, df 4 4, P < 0.0001; females, x2 4 20.1, df 4 4, P < 0.0005). More male than female doctors feel confident at giving specific advice (x2 4 37.1, df 4 2, P < 0.0001). There were no significant difference when responses were analyzed by years in practice or by age controlling for sex. Walking is the activity most frequently recommended to otherwise healthy, sedentary, adult patients to improve fitness (Table 4). There was no significant difference between the reported current practice (do you) and the reported desirable practice (should you) for each type exercise. However, male doctors are more likely to advise vigorous or less vigorous activity than female doctors (x2 4 21.2, df 4 4, P < 0.001). Although over three-quarters of the doctors report currently providing the patients with details of the frequency, intensity, and duration of exercise (84, 76, and 77%, respectively), current practice fell short of

FIG. 1. tice.

Methods to promote exercise: current and desirable prac-

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HOW CAN AND DO FAMILY PHYSICIANS PROMOTE PHYSICAL ACTIVITY?

TABLE 2 Referral as a Method to Promote Physical Activity—Current and Desirable Practice

Referral to fitness centers Referral to qualified exercise personnel Referral to other staff in practice

Current practice (%) (n 4 392)

Desirable practice (%) (n 4 397)

Often and almost always

Agree and strongly agree

x2

df

P

10.1 13.2 0.8

31.2 46.9 13.3

84.9 174.6 129.9

2 2 2