Primary care staff's views and experiences related to routinely advising patients about physical activity. A questionnaire survey

The benefits of regular physical activity (PA) include improved physical and mental health, as well as an enhanced quality of life [1–3]. Yet, despite the generally high levels of awareness of the benefits of being active within the general population, there is continuing evidence of declining levels of PA both in England and Scotland [4]. This trend has been strongly linked to increasing levels of coronary heart disease, type II diabetes, osteoporosis, colon cancer and obesity. Currently, national recommendations stipulate that adults should accumulate a minimum of 30 minutes of moderate level PA (the equivalent of brisk walking) most days of the week (30 mins PA ×5) [5].

Whilst it is recognised that policies recommending that general practitioners (GPs) promote physical activity are not universally accepted [6, 7], many consider that primary care (PC) health professionals are well placed to encourage both increased levels of PA within the general population, as well as with high-risk patients [8, 9]. In addition, it has been reported that PA can alleviate the symptoms of mental health illness, and that it has been found that GPs have been generally reluctant to counsel those patients suffering from mental health problems to consider increasing their PA levels to ameliorate their condition [3].

Health professionals working in PC settings are considered an important part of a wider public health drive to encourage more people to become active [5]. A recently published systematic review of the effectiveness of public health interventions aimed at increasing PA among apparently healthy adults indicated that there is some evidence of short-term changes in PA levels than can be attributed to brief advice given by a health professional [10]. This work also found that longer-term change may result if the individual is referred to an exercise specialist in the community. In addition, there is some evidence to suggest that PC-based exercise referral schemes may result in short-term impacts on PA levels for certain population groups, in particular the 'almost-active' [11].

In championing the role of PC in motivating and supporting the general population to become more physically active, Taylor highlighted the need to understand the range of multilevel and multi-sectoral factors (based on a whole systems approach) that influence the effectiveness of any health promotion programme or intervention [9]. Based on the PROCEED PRECEED health promotion planning model [12] he argued that an investigation of the PC consultation needed to include consideration of three key dimensions including: (1) predisposing factors; which relate to attributes and characteristics of the patients; (2) reinforcing factors which the PHC staff member brings to the consultation; and (3) enabling factors which relate the availability of resources, referrals, rules and protocols, and service structures.

Reinforcing factors in this context relate to the attitudes, knowledge, beliefs and behaviours of those professionals regarded as instrumental in motivating and supporting patients to become more physically active, and Taylor argued that there has been a lack of research in this area [9]. Steptoe et al. [13] also maintained that it is crucial to understand the beliefs and practice of those primary health professionals (working at the frontline) to fully appreciate and understand if public health policy changes have been implemented effectively.

To date, there is a little Scottish empirical data available to policy makers about such reinforcing factors [14]. The few studies that have been conducted elsewhere found that GPs were more comfortable discussing PA with high-risk groups, especially when linked to exercise prescription schemes [15]. Factors preventing routine PA advising included: lack of time; lack of financial reimbursement; relevance to patient's presenting condition; perceptions of poor patient compliance; lack of confidence in providing advice; insufficient knowledge about the benefits of exercise; and a lack of appropriate tools to assess and prescribe exercise [16–20]. Lack of self-efficacy associated with ability to motivate patients and achieve the desired outcome has also been identified [21, 22] as another barrier. Typically, studies have failed to explore the views and practice of the range of health professionals groups within the same study.

A questionnaire was developed following a review of the literature, with selected questions taken from a previous study [18]. Four health board regions in Scotland, (from a possible 15) were selected for the study to reflect a cross section of urban, remote and rural regions. Following a pilot study, the questionnaire was mailed to all GPs (802) based in all 180 practices in the four health board areas in Scotland, as well as 317 PNs and 289 HVs. A mailing list for all principal GPs in each of the four health regions was obtained from ISD (Information Services Division) Scotland. The questionnaire was personally addressed to each GP and then generically to the PN and HV in each practice (no personalised mailing list was available for these professional groups). Reminders were posted after three weeks. Data was analysed using SPSS ver12.0. Chi-squared tests were used to test for associations between categorical data. Normally distributed continuous data were analysed using were using t-tests. Ethical approval was granted by the Scotland (A) Multiple Research Ethics Committee.

The current state of respondents' knowledge related to the PA recommendations is of concern, particularly when most respondents thought they had sufficient knowledge to promote this issue. However, study respondents also reported a lack of appropriate training and development opportunities for health professionals.

At the same time, the majority was supportive of PA promotion as a core aspect of PC, indicating a positive foundation in which to develop further work in this area. However, there does not appear to be a pattern of systematic assessment and practice related to giving PA advice across each study group. It is important that patients receive clear and consistent messages about PA from the wide range of health professionals working within PC as a routine aspect of healthcare. The development of tools and guidelines may assist staff to provide consistent, accurate and appropriate advice tailored to individual patient needs. Training and development activities may also help to raise awareness about related issues. Financial remuneration alone may not be a sufficient incentive to encourage more GPs to promote PA within their practice.

It was surprising to find that HVs and PNs were more likely than GPs to report that they gave PA advice routinely, while at the same time believing population levels of PA to be increasing. It is possible that small groups of patients are increasingly discussing the issue with their HV or PN, where time constraints appear to be less of an issue than for GPs, making it easier for patients to discuss their PA behaviour. However, it was beyond the scope of this study to explore these findings in detail, and it certainly requires further investigation. It is particularly important to understand this issue more clearly when one also considers the lower levels of knowledge about current PA recommendations, amongst the nursing groups, but their generally higher levels of support and enthusiasm for PA promotion compared to GPs. With the expanding public health role of nurses within PC, it seems there is even more potential to reach a large proportion of the UK population. However as we stressed earlier, it is crucial that the advice provided throughout is accurate, credible and consistent.

Nursing groups in also appeared to believe they were more likely to motivate patients to comply with their PA advice than GPs. Why is GP self-efficacy about this issue low and what can be done to enhance it? These are important questions for policy makers, which need to be considered seriously if the health improvement policy aspiration about making PA promotion a routine aspect of primary health care can be realised. For, as evidence on the dynamics of motivation suggests, those who do not expect positive outcomes from engaging in certain behaviours have no motivation to invest in them [33].

This study was limited to an exploration of the beliefs, attitudes and practice of some of the health professional groups who work in PC. It would be useful to have data about other relevant groups not covered by this study, e.g. community-based physiotherapists and district nurses, given their combined potential to reach an even larger section of the population with PA advice. Furthermore, this work is based on self-reported behaviour. Future studies might benefit from the inclusion of observational methods to validate claims of practice. In addition, in order to enhance the efficacy of PC-based approaches to PA promotion there is also a need to investigate the role that predisposing patient attitudes and beliefs, and, existing system or organisational capacity and mechanisms (e.g. protocols and guidelines) plays.

Finally, policymakers, respective professional bodies and health improvement agencies should consider addressing these findings, nationally and locally, if public health policy aims about fully engaging PC staff in efforts to encourage and support the general population to be more physically active are to be effective.