Regular articleExercise counselling by family physicians in Canada
Introduction
Numerous studies have shown that regular physical activity has a role in the prevention and control of many chronic diseases [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]. These include inverse dose-response relationships between physical activity and cardiovascular disease, hypertension, hypercholesterolemia, type II diabetes mellitus, and mortality [2], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23]. Furthermore, increased positive affect, stimulation of creative thinking, increased energy, reduced stress, enhanced self-esteem, and quality of life are also by-products of regular physical activity [24], [25].
Despite the overwhelming evidence that physical activity is beneficial to those with or without a health condition, only 40% of Canadians are active enough to benefit their cardiovascular health [26]. More North Americans are at risk for coronary heart disease from inactivity than any other risk factor [27], [28].
Physician exercise counselling is a new area of study. According to the U.S. Preventive Services Task Force [29] there is currently insufficient evidence to recommend physical activity counselling to patients by physicians in primary care settings. Results from controlled trials have been mixed and most studies have been done on adults with variable levels of baseline physical activity [29]. So far, multicomponent counselling-(verbal advice, written prescriptions, educational booklets, telephone counselling, interactive mail, and behavioural counselling) seems to produce the greatest increase in patient physical activity levels compared to just physician verbal advice [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39]. With the exception of The Physical Activity Counseling Trial [30], follow-up for exercise counselling studies has not been done beyond 1 year, so increases in patient physical activity are short term. Furthermore, there is no standardization regarding measurement of exercise outcomes, exercise counselling content, exercise counselling techniques, and patient psychological readiness. Therefore, the ability to compare these studies is limited.
Family physicians in Canada are in an ideal position to promote physical activity. They are the primary care gate-keepers to the medicare system in Canada and see patients on a repetitive basis for health concerns. Up to 95% of Canadians consider their family physician the health professional they consult first [40]. Thus, exercise counselling in the family physician setting has the potential to reach many Canadians.
Previous exercise counselling surveys [41], [42], [43], [44], [45], [46], [47], [48], [49], [50] have examined counselling frequency, perceived knowledge, and confidence in exercise counselling and barriers to exercise counselling. The literature shows variation in exercise counselling frequency by physicians from 33–93% [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], with Canadian studies demonstrating the higher counselling frequencies [49], [50].
Few studies have assessed physician ratings of confidence and knowledge in exercise counselling. Petrella and Wight [50] found 67% of the physicians they surveyed were confident in their exercise counselling advice. Reed et al. [42] showed 27% of primary care physicians felt very knowledgeable in exercise counselling. Physicians were more pessimistic about their ability to translate their knowledge into patient change. Stevenson and McKenzie [49] reported that only 5.3% of physicians believed they were very successful in changing a patient's exercise behaviour.
Barriers to exercise counselling identified in previous studies [41], [43], [45], [49], [50] are very similar. The most common barriers cited include lack of time, lack of continuing education in the subject area, and inadequate reimbursement to do exercise counselling.
Currently, there are no Canadian studies that evaluate exercise counselling across several provinces. The purpose of this study was to assess the following variables as they pertain to the practice of exercise counselling by family physicians in Canada, by use of a pretested questionnaire: (1) confidence, (2) perceived knowledge, (3) perceived qualifications, (4) current exercise counselling practice frequency, (5) physician's desired frequency of exercise counselling practice (desired practice), and (6) barriers related to the counselling of exercise by family physicians.
Section snippets
Questionnaire design and pretest
A 36-item, two-page doubled-sided questionnaire was designed specifically for this study. In this study, we listed a definition of exercise as continuous physical activity according the American College of Sports Medicine (ACSM) guidelines [51]. We wanted physicians participating in the study to have the same definition of exercise. “Exercise” was considered to be continuous physical activity. “Exercise counselling” was defined as the encounter where:
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a physical activity history (and medical
Results
A total of 79 of the 747 questionnaires mailed out were not completed because the physician could not be located, or was not currently practicing. Reasons for not being able to locate the physician included an incorrect address, incorrect phone number, or physician had moved. Reasons for the physician not practicing included personal or professional leave of absence, retired, or on vacation.
From the remaining 668, a total of 459 responded and completed the questionnaire. There were 209
Discussion
The response rate of 61.1% was consistent with past physician surveys [41], [42], [43], [45], [47], [49], [53], [54], [55]. The exception to this was the study by Petrella and Wight [50], which reported a response rate of 90.5%. In their study, physicians were initially contacted by phone. They were asked demographic questions and questions about their exercise counselling behaviour before they were mailed a questionnaire. This initial verbal contact may have encouraged more physicians to
Conclusion
This project was the first Canadian study that surveyed family physicians in equal proportions from six provinces in Canada on the subject of exercise counselling. It identified problematic barriers and suboptimal levels of exercise counselling practice and perceived knowledge. Future research is required to determine the type of exercise education, counselling tools, or health system changes that could assist family physicians to do more exercise counselling.
Acknowledgements
This research project was supported by the College of Family Physicians of Canada Research and Development Fund and the University of Calgary Sport Medicine Centre.
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