Reinforcing factors
Knowledge
The relatively low levels of knowledge and accuracy in describing the current PA guidelines were surprising, particularly given that the recommendations for sedentary adults are currently present in several national guidelines, such as, management of lipids and prevention of coronary heart disease, and diabetes management [23, 24]. Furthermore, surprisingly high numbers of HVs and PNs thought that levels of PA were increasing in the population. Most GPs believed the reverse was true. One can question whether it is possible that this finding has arisen due to the context within which the patient consultation occurs, i.e. where patients maybe more likely to disclose their PA experiences in a less formal and time pressured atmosphere. If this was the case, one might argue that GPs would be less likely to hear patients' accounts of their attempts at PA behaviour, compared to PNs and HVs. However, this apparent lack of knowledge about PA recommendations and current population trends is concerning, as, well-informed health professionals are considered essential for effective delivery of PC-based health promotion [25].
Advising practice
Most PC staff said they currently advised patients about PA during routine consultations. However, there was variation in practice between HVs and PNs on the one hand and GPs on the other. For example, HVs and PNs (~90%) were more likely to intervene with advice than GPs (~70%). It is possible that this effect could be explained by the finding that also indicated that GPs were more likely to discuss PA if they perceived it as relevant to a patient's presenting condition.
All PC groups were more likely to intervene with PA advice if they thought the patient was overweight. Proportions of respondents who advised staff for other conditions was generally very low. These findings are consistent with other studies [16, 17]. However, HVs were more likely to discuss PA with patients suffering from depression and discuss psychological benefits than GPs or PNs. This difference is interesting in light of the findings reported by the Mental Health Foundation, which also indicated that very few GPs considered providing advice about exercise for those with mild to moderate depression [3].
Walking was the most popular form of exercise recommended by all groups. This is encouraging, as walking advice is considered most relevant for those who are currently sedentary, and/or are from lower socio-economic backgrounds; who also consistently report lower levels of PA [26].
While it is reassuring to observe that PC staff appear to be giving generally sound advice, for example, most were unlikely to advise patients to take vigorous PA – there could be more clarity about the message given, particularly as the correct advice currently exists in clinical guidelines. However, the lack of use or adherence to clinical guidelines amongst GPs remains a challenge [27].
Attitudes
The majority of study respondents expressed positive views about health promotion as a core aspect of PC; with 90% of all respondents indicating that they believed PA promotion in PC was important. In addition, the majority indicated they would discuss PA with their patients, even if it was not raised during the consultation. These findings indicate that there is good practitioner support for PA promotion in PC.
Whilst respondents had an apparent lack of knowledge about the current guidelines, paradoxically, most thought they had sufficient knowledge to promote PA with their patients. Perhaps these apparently contradictory findings indicate a general lack of awareness or understanding about current behaviour change approaches to counselling. Nevertheless, it is important to raise awareness amongst each professional group about current PA recommendations, preferably in the context of increased education and training opportunities, which study respondents also indicated they needed.
While GPs were more inclined to mention lack of remuneration as a barrier than PNs or HVs, less than one in four agreed with this statement. The fact that there are significant differences between GPs and nurses about this issue is perhaps not surprising given the different methods of remuneration for each group. Moreover, our findings suggest that GPs were less likely to be motivated by financial rewards than other studies have indicated [17].
In terms of other significant differences in study groups' views, lack of time was considered more of a barrier to routine PA advising for GPs than it was for PNs and HVs. However, only 50% of GPs thought lack of time was a barrier compared to 93% in a similar study [18]. It is possible that this is a secular effect brought about by the changes in PC priorities over the last five years, which have witnessed an increased emphasis on health promotion and health improvement.
Another perceived barrier worth highlighting is that GPs were less likely to think that patients would be motivated to follow their advice compared to HVs and PNs. This may be indicative of higher levels of self-efficacy related to patient motivation in the nurse groups compared to GPs. Low GP self-efficacy has also featured in other studies [20–28]. However, further study is needed to investigate why this is the case, and if those who perceive themselves to be likely to motivate patients to change their behaviour are effective in doing so.
Predisposing and enabling factors
This study focussed on individual level or 'reinforcing factors' [12] associated with PC professionals' attitudes and beliefs associated with PA promotion. However, if PC is to be effective in embedding policy within practice, other dimensions such as patient characteristics, so-called 'predisposing factors' and, the system capability or 'enabling factors' such as service structures, resources, protocols [29] need to be considered.
It is essential to understand patients' perspectives, particularly about the relevance, acceptability and impact of PC staff intervening with PA advice during routine consultation. Some qualitative studies are starting to shed a little light on these issues. We know for instance that patients regard GPs as a credible source of advice, and some do seek their GP's help with gaining access to exercise referral schemes [30]. However, evidence suggests that these individuals may be actively contemplating becoming more physically active in the first place [11]. It may be possible that other patient groups believe GPs have the necessary knowledge, but limited time in which to routinely advise them on the issue, and are therefore not raising it during a consultation with their doctor. Nevertheless, evidence about patient's perspectives is scarce. Further patient-centred research may also yield data about the validity (or otherwise) of each of the respective professional group's views about their efficacy in motivating patients to be more physically active.
Our findings concur with Eakin and colleagues [29] who found in their review of physician barriers to PA counselling provision, that practitioner reports of system barriers (e.g. lack of time, resources, training and protocols or guidelines) continue to feature alongside individual level barriers associated with PA promotion, such as not having the requisite knowledge, skills, efficacy etc, needed to motivate patients to change. They maintain that the development of PC based, PA interventions must therefore take account of organisational systems and structures if such initiatives can feasibly be adopted and implemented by busy staff working in the real world. They and others [31, 32] also highlight the need to develop tools and guidelines to support staff to promote PA. Our that respondents believe that there is a lack of educational tools and training for staff to support individual practice, but it was beyond the scope of the study to investigate such issues in detail and further work is required to identify what is required.
Strengths and limitations of the study
The survey achieved a reasonable response rate given the timing of the survey, which coincided with the new GP contract in the UK. Another study of GPs' beliefs and behaviour related to health promotion gained a 48% response rate [13]. However, we also believe that this is the largest survey of its kind of PC professionals from any one health care system.
It is possible that the generally very positive responses to questions associated with the relevance of this issue within PC reflect the views of the "enthusiasts". However, the demographic characteristics of our GP respondents are similar to the national picture, and the characteristics of the GP non-responders were similar to the responders, suggesting that our sample is representative.
Our study was also limited to these particular study groups for pragmatic reasons. Clearly there are other health professionals working in PC whose beliefs and practice related to this issue should also be understood. Nevertheless this is the first study to our knowledge that has attempted to capture a range of PC staff in the same survey on this issue.
Whilst there are clearly some similarities between ours and others findings e.g. barriers to routine advising related to a perceived lack of time and relevance to the patient's presenting condition, there were differences related to the perceived role financial remuneration could play in encouraging routine PA advising amongst GPs. In addition, other studies did not ask respondents about their current knowledge and beliefs about current PA recommendations, or their perceptions about the general levels of PA in the population. We believe these factors may have a bearing on whether staff will intervene with advice (or not) and the nature of the advice that is given.