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Original article
General practitioners’ perceptions and practices of physical activity counselling: changes over the past 10 years
  1. L M Buffart1,
  2. H P van der Ploeg2,
  3. B J Smith3,
  4. J Kurko4,
  5. L King5,
  6. A E Bauman2
  1. 1
    Department of Rehabilitation Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
  2. 2
    Centre for Physical Activity and Health, University of Sydney, Sydney, New South Wales, Australia
  3. 3
    Department of Health Science, Monash University, Frankston, Victoria, Australia
  4. 4
    National Heart Foundation of Australia, Sydney, New South Wales, Australia
  5. 5
    Centre for Overweight and Obesity, University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Hidde van der Ploeg, Level 2, Medical Foundation Building (KZS), University of Sydney, Sydney 2006 NSW, Australia; hiddep{at}health.usyd.edu.au

Abstract

Objective: In this work, trends in general practitioners’ (GP) knowledge, confidence and practices in promoting physical activity to patients over a 10-year period (1997–2007) were studied.

Design: Repeated cross-sectional population survey

Setting: General practice in New South Wales (Australia)

Participants: 646 (40%), 747 (53%) and 511 (64%) GPs that were registered in a selection of urban and rural divisions in New South Wales participated in 2007, 2000 and 1997, respectively.

Main outcome measures: Self-report questionnaire on the GP’s knowledge, confidence, role perception, attendance of continuous professional development and counselling practice with regard to promoting physical activity in their patients were the main outcome measures.

Results: The majority of GPs felt confident in giving physical activity advice and saw it as their role to do so. The proportion of GPs with high confidence and role perception increased between 1997 and 2000 (p<0.001) but remained unchanged thereafter. In 1997, GPs were 0.54 times less likely (95% CI 0.42 to 0.69, p<0.001) to discuss physical activity with more than 10 patients per week than GPs in 2007. However, the percentage of new patients that were asked about their physical activity did not change over the last decade.

Conclusions: Most increases in the proportion of GPs reporting high knowledge, role perception and confidence in giving physical activity advice to patients occurred between 1997 and 2000 and remained unchanged thereafter. In 2007, GPs appeared to give more physical activity advice, but Australian general practice is not yet living up to its potential with regard to physical activity promotion.

https://doi.org/10.1136/bjsm.2008.049577

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    The importance of a physically active lifestyle is well known. Health benefits include a lower risk of hypertension, diabetes, cardiovascular disease, some forms of cancer as well as improvement in weight loss or maintenance, fitness and quality of life.1 2 Physical inactivity is recognised as a leading contributor to the total burden of disease.3 4 With more than half of the Australian population being insufficiently active,5 this is a more prevalent risk factor than obesity or smoking, which highlights the importance of finding effective strategies to increase population physical activity levels.6

    General practice should be an important setting for promoting physical activity for several reasons. First, general practitioners (GPs) can reach a large population because the majority of Australian adults visit a doctor at least once a year.7 Second, patients have identified GPs as a credible source of information and advice on physical activity.8 9 10 Third, GPs usually have long-lasting relations with their patients,11 which enable them to offer longer-term counselling and follow-up. Fourth, a range of intervention studies12 13 14 15 and a number of reviews of this literature16 17 18 19 20 reported that GP advice and counselling can result in increased adoption of physical activity by patients, at least in the short to medium term.

    The American College of Preventive Medicine takes the position that primary care should incorporate physical activity counselling into routine patient visits.21 Furthermore, in Australia, recent initiatives have included programs and networks under the Active Australia Campaign, the formation of national and state-based coalitions,22 the distribution of prescription and written materials for promoting physical activity and providing GPs with continuing professional development (CPD) on physical activity and health. Furthermore, there have been efforts to create active communities22 and increased media attention towards physical activity and obesity.23 24 In light of this, it is worthwhile to investigate how GP practice has changed in regard to physical activity.

    Data collected in 1997 and 2000 showed that GPs have improved their knowledge about the health benefits of physical activity, their confidence in giving physical activity advice, and more believed it was their role to do so. However, reported patient counselling did not change during this period.25 Continuing with the monitoring of GP perceptions and practice of physical activity counselling, the same survey of GPs as in 1997 and 2000 was undertaken in 2007. The aim of the study was to assess GP knowledge, confidence, role perception and frequency of discussing physical activity behaviour with patients in 2007 and to determine whether changes have occurred since 1997 and 2000.

    Methods

    Sampling

    In March 2007, we mailed a questionnaire to all GPs (n = 1624) who were registered within one of five urban (Canterbury, Macarthur, Hawkesbury-Hills, Central Coast and Hunter Urban) and two rural (southeast New South Wales and central west) divisions of the 37 divisions of family practice in New South Wales, Australia. The Divisions were purposively selected to provide a mix of urban and rural settings in New South Wales. To improve the response rate, we mailed one reminder to GPs and awarded small prizes to six randomly selected GPs who returned the survey. This was the third survey in a series of GP perceptions and practice of physical activity counselling after those conducted in 1997 and 2000, which are described elsewhere.25 In 1997 and 2000, questionnaires were mailed to 796 and 1404 GPs, respectively. The research committee of The Royal Australian College of General Practitioners New South Wales Faculty approved the study.

    Measurements

    Questions concerning GP knowledge, confidence, role perception and practice were the same as those asked in 1997 and 2000.25 The questionnaire contained five items on the GP knowledge about the amount of physical activity required for health benefits in adults. It contained two items on the confidence in promoting physical activity and three items on the perception of their role in physical activity promotion. The questions consisted of statements to which respondents were asked to rate their agreement on a five-point Likert scale (“strongly agree” to “strongly disagree”). GPs were asked how many patients they discussed physical activity with in the previous week and about the percentage of old and new patients they usually asked about physical activity. In addition, they were asked about participation in CPD sessions on physical activity and health. Data collected about respondents included sex, average number of years in practice, patients seen per week and hours worked each week.

    Statistical analyses

    We tested differences in sex and area (rural vs urban) of respondents among 1997, 2000 and 2007 using a χ2 statistic and differences in the number of years in practice and the number of patients seen per week using a one-way ANOVA and using a Bonferroni post hoc correction to determine differences between the three survey years. We considered p⩽0.05 as significant.

    We dichotomised the Likert scale outcomes by combining the two “agree” options and combining the “neutral” and the two “disagree” responses and the frequency of discussing physical activity with patients at 10 or more patients per week. For these outcomes, we performed multiple logistic or linear regression analyses to compare results from 2007 with those from 2000 (n = 747) and 1997 (n = 511). We checked the following variables for potential confounding or effect modification: GP’s sex, average number of patients seen per week, number of years in practice and area of practice (rural vs urban). Additional logistic modelling examined whether the proportion of GPs attending CPD had changed compared with 2000 and 1997 and whether those who attended CPD were more likely to discuss physical activity with patients.

    Results

    Characteristics and differences across surveys

    In total, 646 (40%), 747 (53%) and 511 (64%) GPs responded to the survey in 2007, 2000 and 1997, respectively. The characteristics of these responding GPs are shown in table 1. In 2007, 58% of the participating GPs were men; on average, they had been in practice for 21 years, they saw around 118 patients per week, they worked for 37 h each week, and 78% were from an urban area. Several differences in characteristics across the surveys were found. In 2007, the percentage of men was 7% lower than that in 2000 (p<0.001) and 14% lower than that in 1997 (p<0.001). On average, GPs responding to the 2007 survey had been 4 years longer in general practice (p<0.001) and received less patients per week (p<0.001) than the GPs who responded to the 1997 and 2000 surveys. The distribution over rural or urban areas in 2007 was comparable to that in 2000, but the proportion of GPs based in urban areas was 24% higher than in 1997 (p<0.001), reflecting the variations in divisions from which GPs were recruited between these two surveys. However, these variations in divisions were acceptable because the practice area did not appear to be a confounder or effect modifier.

    View this table:
    Table 1

    Response rate and characteristics of responding GPs in 1997, 2000 and 2007

    Knowledge, confidence, role perception and counselling

    Table 2 presents the findings concerning GP knowledge, confidence and role perception regarding physical activity advice and the frequency of discussing physical activity with patients, and it also includes results of the linear and logistic regression analyses comparing results of 2007 with those of 2000 and 1997. GP’s number of years in practice and the number of patients seen per week were potential confounders, adjusted for in all multivariable analyses.

    View this table:
    Table 2

    GP knowledge, confidence, role perceptions and practice with regard to physical activity promotion in 1997, 2000 and 2007

    In 2007, the number of GPs believing that “taking the stairs and generally being more active each day is beneficial for health” and that “10-min bouts of walking on most days are better than just one longer session per week” remained unchanged from 2000, but both items improved from 1997 (p<0.001). Compared with 2000, fewer GPs in 2007 believed that half an hour of walking on most days is all the exercise that is needed for good health (odds ratio (OR) for 2000, 2.24; 95% CI 1.73 to 2.90) but results were comparable to 1997. Compared with 2000, more GPs in 2007 believed that vigorous activity is necessary to obtain health benefits (OR for 2000, 0.54; 95% CI 0.43 to 0.68) and that exercise must make you puff and pant (OR for 2000, 0.36; 95% CI 0.27 to 0.49).

    In 2007, nearly all GPs felt confident about giving physical activity advice to patients, which was similar to 2000, and it was 10% higher than in 1997 (OR for 1997, 0.46; 95% CI 0.32 to 0.67). Similar to 2000, almost all respondents in 2007 believed that they had a role to help patients to become more active, and this proportion increased from 91% in 1997 to 98% in 2007 (OR for 1997, 0.22; 95% CI 0.12 to 0.42). In 2007, the number of GPs discussing physical activity with more than 10 patients per week was 10% and 9% higher than in 1997 and 2000, respectively (OR for 1997, 0.54; 95% CI 0.42 to 0.69; OR for 2000, 0.58; 95% CI 0.46 to 0.74). In 2007, GPs asked 57% of new patients and 46% of patients seen previously about their physical activity participation. Although these percentages had increased significantly since 2000 (β for 2000 = −4.12; 95% CI −7.58 to −0.65), they were not different from those in 1997.

    CPD about PA and health

    In 2007, 43% of GPs reported to have attended CPD about physical activity and health, which was lower than that in 2000 (p<0.001) and 1997 (p<0.001) (table 2). In 2007, GPs who attended CPD were 2.17 (95% CI 1.54 to 3.04) times more likely to discuss physical activity with 10 patients or more per week than those who did not receive CPD (p<0.001) after adjusting for number of years in practice and number of patients seen per week.

    Discussion

    This study showed that over the past 10 years, an increased proportion of GPs reported having high knowledge and confidence in giving physical activity advice and seeing it as their role to do so. Most improvements occurred between 1997 and 2000, which were sustained in 2007 but did not increase further, despite Australian efforts and initiatives over the past years. Nevertheless, in 2007, GPs appeared to give more physical activity advice, but they could still play a much greater role in physical activity counselling to contribute to public health efforts to increase population physical activity levels.

    The present data showed that GPs realise that generally being more active is beneficial, but compared with 2000, they are less likely to think that moderate-intensity physical activity is enough. We hypothesise that this shift towards greater emphasis upon the importance of vigorous-intensity exercise may be related to the rise in prevalence of overweight and obesity in the population26 and its increased media attention.23 To prevent and reduce overweight and obesity, the minimum recommended amount of 30 min/day of moderate physical activity on 5 day/week is not sufficient, and physical activity should be more of moderate to vigorous intensities and of longer duration per day.2 The observed changes in the knowledge of GPs towards physical activity may reflect the growing focus on obesity in physical activity recommendations.

    Previous studies reported GP’s lack of knowledge, lack of confidence, lack of time and lack of appropriate tools to assess and prescribe exercise as important factors preventing routine physical activity counselling.11 27 28 29 However, in addition to good knowledge, the present results showed that almost all GPs felt confident in giving physical activity advice, and that they saw it as their role to do so. The fact that a further increase in confidence and perceived role was not found after 2000 was probably caused by a ceiling effect.

    Despite evidence of confidence and a perceived role in physical activity counselling, this has not become a routine practice for GPs yet, as 43% of new patients and more than half of patients already seen are not asked about physical activity. The 10% increase in the proportion of GPs who give physical activity advice to at least 10 patients per week was encouraging, but there is still a considerable scope to improve on this, particularly given the relevance of physical activity to many of the conditions that GPs encounter in their patient consultations. There is a need for further research to identify strategies to build and reimburse preventive counselling into routine practice.

    In 2007, fewer than half of the GPs reported CPD attendance. This proportion is considerably lower compared with the previous years, which may reflect changes in CPD opportunities. As GPs who attended CPD were more likely to counsel on physical activity than those who did not, CPD attendance should be encouraged among GPs, and appropriate CPD opportunities should be created. However, CPD alone seems to be insufficient considering the small changes in counselling behaviour of GPs. It is therefore important to move beyond “information-only” strategies towards structural changes including policy, environmental supports30 and practice systems31 that will support the adoption of evidence-based programs into practice. This might include non-physician members (ie, practice nurse) of the primary care team in intervention delivery, as well as use of technological tools.32 33 34 Another promising path is to link primary care with community opportunities to support for physical activity.35 36 37 In addition, local media may also be important to widely broadcast information on the importance of physical activity, as well as highlighting the role of primary care in promoting physical activity.33

    Several attempts have been made to effectively translate research into practice. The 5A approach (assess, advise, agree, assist, arrange) provides a clear structure for promoting physical activity in general38 and may be a useful tool to get GPs into action. Furthermore, the reach, efficacy, adoption, implementation, maintenance framework, which includes both individual and organisational levels of impact can be used to evaluate whether interventions are translatable into practice.36 39 40

    A limitation of the present study was the decline in response rates in 2007 compared with previous years, which might have introduced selection bias with GPs who are more interested in the topic being more likely to have participated in the survey. This may have resulted in an overestimation of the knowledge, confidence, perceived role and counselling behaviour. The strength of the current study was that all registered GPs in several rural and urban areas were approached, which formed a good representation of New South Wales practices.

    Another source of bias could have been the use of self-report measures, which are susceptible to social desirability and recall bias. The strength of this study was that it monitored trends in GP knowledge, role perceptions and practices over the past 10 years using the same questions and methodology, so measurement bias was likely to be non-differential and should not have affected the direction of the trends observed.

    In conclusion, over the past 10 years, the proportion of GPs in New South Wales reporting high knowledge on physical activity and health, confidence in giving advice and role perception with respect to physical activity promotion increased. However, most increases occurred between 1997 and 2000 and remained unchanged thereafter. In 2007, the number of GPs discussing physical activity with patients in the previous week was slightly increased. Yet, a large proportion of patients visiting GPs are still not advised about the important health issue physical activity, indicating that Australia’s efforts and initiatives have only had limited effect, so far, on GP practices. This highlights that this is a long-term challenge, and strategies to improve population physical activity levels should move beyond providing information only. Future research should focus on finding more effective strategies to translate research into widespread practice to increase GPs’ counselling behaviours and may include structural changes in policy, environmental support and practice systems.

    What is already known on this topic

    • A physical inactive lifestyle has major health risks.

    • General practice has been identified as a setting that should have a major role in the promotion of population physical activity levels.

    • Information on changes in perceptions and practices of general practitioners with regard to physical activity promotion over the last decade is limited.

    What this study adds

    • Over the last decade, general practitioners increasingly see it as their role to promote physical activity, improved their knowledge and feel confident to give physical activity advice.

    • However, general practice is not yet playing the major role that has been projected for it in physical activity promotion.

    Acknowledgments

    The authors thank all participating GPs.

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    Footnotes

    • Funding Funding of the survey field work was supported by the National Heart Foundation of Australia. The Trustfonds (Erasmus University Rotterdam) provided a grant to the first author for a working visit to the Centre for Physical Activity and Health (University of Sydney).

    • Competing interests None.

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