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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
<0.0001 <0.0001 <0.0001
perceived desirable practice. Significantly more doctors indicated they should provide information on frequency (90%; x2 4 7.0, df 4 2, P 4 0.03), on intensity (87%; x2 4 20.0, df 4 2, P < 0.0001), and on duration (87%; x2 4 17.1, df 4 2, P 4 0.0002). The three barriers judged as ‘‘most likely’’ to affect a patient’s participation in exercise were lack of motivation, lack of time, and family commitments. Just over half of the doctors thought lack of support, lack of company, and being overweight were also likely to affect participation. Few doctors thought fear of injury (8%) and cost (16%) were important factors (see Table 5). We looked for any differences in perception of barriers to exercise between male and female doctors and younger and older FPs (controlling for age). Female doctors are significantly more likely to perceive cost (P < 0.0005), family commitments (P < 0.01), lack of time (P < 0.05), ethnic background (P < 0.05), and lack of confidence (P < 0.05) as barriers to participation than are male doctors (see Table 5). Younger male physicians (<35 years of age) are significantly more likely to perceive ‘‘too much effort’’ (x2 4 20.9, df 4 6, P < 0.005), ‘‘lack of time’’ (x2 4 15.8, df 4 6, P < 0.01), and ‘‘lack of confidence’’ (x2 4 14.7, df 4 6, P < 0.5) as important than do older doctors. Numerous small cells precluded statistical analysis of relationships across age for female physicians.
et al. [41] and Wells et al. [42], we found verbal advice to be the most frequently used technique. Less than 20% of the doctors almost always provided written information in the consultation and in the waiting room. This is despite evidence supporting the additional impact of written material when it is used to supplement verbal advice from doctors [43,44]. The infrequent use of written material may be due to its availability, accessibility, and practicability in the setting of family practice—just finding a pamphlet when it is needed can be difficult! Some doctors believe that pamphlets are ineffective and that patients do not use them [32]. Videos are used by few doctors and are not seen by many as a method that they should be using regularly. We did not explore whether this was due to concerns about establishing and running a system for lending videos to patients, about the availability and cost of videos, or about the proven effectiveness of videos as a method of promoting exercise to patients. In contrast, Kushner found that 50% of the 1,103 primary care physicians surveyed were interested in home video demonstration tapes [45]. Given the pressure on FPs to undertake opportunistic health promotion, we were interested in the current use of, and support of, referral systems as a method to promote exercise to patients. About 10% of doctors cur-
DISCUSSION
TABLE 3 Family Practitioners’ Confidence in Giving Advice on Physical Activity
We developed two questionnaires to assess current practice (do you) and perceived desirable practice (should you) in the promotion of physical activity by family practitioners. To avoid influencing self-report on current practice each doctor completed only one of these questionnaires. The credibility of our results was enhanced by including in the sample all family practitioners in the study area and by the corrected response fraction of 71%. It is acknowledged, however, that selfreports of usual practice are subject to error and may be biased in the direction of perceived desirable practice. This survey addressed the methods that doctors were currently using, or thought they should use, to promote exercise. Not surprisingly, and like Heywood
I feel able to give general advice on physical activity I feel able to give specific advice on physical activity
Disagree and strongly disagree (%)
Neither agree nor disagree (%)
Agree and strongly agree (%)
Malesa Femalesa Total
1.7 0.8 1.4
7.2 7.5 7.3
91.1 91.6 91.3
Males Females Total
17.1 34.7 22.4
31.5 33.3 32.2
51.4 31.7 45.5
a Denominators are: M 4 543; F4 239; values in the table are row %.
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TABLE 4 Type of Physical Activity Recommended by Family Pactitioners Current practice (%) Type of excercisea Vigorous excercise Less vigorous exercise Physical activity apart from exercise Increase walking as part of daily activities Walking specifically for fitness a b
Desirable practice (%) b
M n 4 260
F n 4 130
Total n 4 392
M n 4 285
F n 4 110
Totalb n = 397
8.4 6.4 1.2 26.6 57.4
2.5 1.7 0 14.0 81.8
6.5 4.8 0.8 22.6 65.3
8.0 9.1 1.1 25.0 56.8
7.3 2.7 0.9 25.5 63.6
7.8 7.2 1.0 25.1 58.9
Repondents could choose only one activity; each column of figures totals 100%. Total may differ due to missing data on sex.
rently refer patients to fitness centers, less than 15% refer patients to qualified exercise personnel, and less than 1% refer to other staff in their practice. A similarly low use of referral systems has been found in other studies [27,41,46], although Biddle et al. [47] report greater use of referral, particularly to in-house programs, by FPs in the United Kingdom. Among Western Australian FPs there was considerable hypothetical support for ‘‘referral to qualified personnel’’ (47% agreed or strongly agreed) while almost a third supported ‘‘referral to fitness centers’’ (31% agreed or strongly agreed). Few supported referral to other staff in their practice which may reflect a reality that there is no one else in their practice with a special interest or skills in promoting or supervising exercise, that everyone else in the practice is as busy as they are, or that doctors are not comfortable referring to colleagues or to other staff within the practice. In the United States, Williford et al. [34] reports that 13% of physicians had staff members whom they indicated developed exercise prescriptions for their patients. An additional openended question found that the small number of doctors who did refer patients to other staff usually sent patients to physiotherapists or dietitians. Similarly, physiotherapists, dietitians, and community nurses received strongest in-principle support as sources of assistance, no doubt reflecting the established channels of referral between FPs and allied health professionals. However, this does raise the question of how much training and experience these professionals have in the promotion and supervision of exercise in otherwise healthy individuals. A ‘‘health promotion officer’’ was mentioned by only three doctors. Even so, the potential of referral systems for the promotion of physical activity should be explored. This survey found that doctors are more confident at providing general rather than specific advice on physical activity to patients. General advice is understood to mean that the doctor mentions to a patient the need to do more exercise but does not specify or discuss types of exercise, frequency of exercise, or how the patient might start increasing their level of exercise. Conversely, specific advice would involve a doctor provid-
ing these and possibly other details to the patient. Doctors could feel less confident about providing specific advice due to the following reasons: a lack of knowledge of the different options for exercise that are available and of which option would be most appropriate to the patient’s needs, a lack of skills and experience in counseling patients on exercise, a perception that lifestyle counseling is ineffective, a lack of time to provide specific advice, or a belief that patients are not interested in hearing advice on changing their lifestyle. Doubts TABLE 5 Family Practitioners’ Knowledge of Barriers to Adoption of Exercise 0Likely0 or 0very likely to affect0 (%)
Lack of motivation a,b Lack of time Family commitmentsc Lack of support from spouse/partner Lack of company to exercise with Overweight Existing illness or injury Small benefit for a lot of effortd Age Lack of confidencea,e Perceived unimportance of exercise Ethnic/cultural backgrounda Lack of knowledge/skills Insufficent access Costf Fear of injury a
Male n 4 545
Female n 4 240
Total n 4 789
90.5 87.3 72.9
91.5 93.3 84.4
90.8 89.1 75.9
53.5
62.0
56.3
54.8 54.3 46.3
59.7 46.9 51.4
56.1 51.8 48.2
42.5 41.7 37.2
39.8 37.6 47.7
41.9 40.2 40.0
39.1 32.8 37.9 28.0 12.1 8.1
40.0 48.6 28.7 34.1 23.9 6.2
39.5 37.5 35.0 30.1 15.5 7.5
Significant difference between male and female FPs (P < 0.05). Significant difference between younger male and older male FPs (P < 0.01). c Significant difference between male and female FPs (P < 0.01). d Significant difference between younger male and older male FPs (P < 0.001). e Significant difference between younger male and older male FPs (P < 0.05). f Significant difference between male and female FPs (P < 0.005). b
HOW CAN AND DO FAMILY PHYSICIANS PROMOTE PHYSICAL ACTIVITY?
about effectiveness of health promotion, lack of skills, and lack of time have been reported in other studies, both in the United States and in Australia [26–28,30– 32]. That some FPs perceive their patients as being not interested in changing their lifestyle is supported by our research on barriers to the promotion of exercise by doctors. As we have shown elsewhere, after ‘‘lack of time’’ and ‘‘lack of resources,’’ ‘‘patient preference for drug treatment’’ is identified by FPs as a barrier to their promoting physical activity more systematically [30]. Nevertheless family physicians do believe exercise is important and, in addition, they report that doctors should be advising all their patients more often than is currently occurring [30,33].These results concur the need for more skills and practice in counseling on exercise reported by both Williford et al. [34] and Sherman and Hershman [31]. We found that male FPs were more confident than female doctors in giving patients specific advice on exercise while there was no such difference in giving general advice on exercise. Other studies have shown differential rates of preventive practices between male and female physicians [48]. For example, female FPs are more likely to undertake screening via mammography and Pap smears than are their male counterparts [49,50]. The results from this study suggest that the content of advice on lifestyle risk factors may also differ between male and female physicians. It is possible that male doctors feel more confident about giving specific advice on exercise due to higher levels of participation in exercise, particularly vigorous exercise, themselves [35,36]. Alternatively, female practitioners may spend more time addressing the barriers to participation rather than the specific details of the type of exercise. This study did find differences between male and female FPs on their perceptions of barriers to exercise, which, if confirmed by further studies, may have important implications for the type of training that is offered to male and female FPs. Research now supports the message that a regular routine of 30 min of walking on most days of the week is sufficient to obtain the benefits to health afforded by exercise [1]. Walking was the form of exercise recommended most frequently by the male and female doctors completing this survey. Similarly, Ruth et al. [32] found that over 50% of doctors in the state of Victoria, Australia, suggested walking when presented with a specific case scenario. Advising patients on walking is consistent with population surveys that have found walking to be the most popular activity for adults wishing to take up (more) exercise [35–37]. We found no significant difference between the current frequency with which each type of exercise was recommended (do you) and the pattern of advice doctors thought represented perceived desirable practice (should you). However, there were differences between male and female doctors in the type of exercise they
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recommend to a sedentary adult that reflect population research showing that more men than women participate in vigorous exercise [35,36]. Not only are doctors recommending walking, an activity that just over 50% of Australian men and women undertake on a regular basis [35], but they are familiar with the common barriers to patients taking up exercise. Consistent with other reports, FPs in Perth perceived lack of time, lack of motivation, and family commitments as the constraints that most affect the adoption of exercise [36,38–40]. One exception was the doctor’s perception of injury as a barrier. In the Pilot Survey of the Fitness of Australians, injury was the third most frequently reported barrier cited by the public across all ages and in both men and women [35]. However, only 50% of the doctors in this survey felt injury to be important and it ranked seventh after lack of company, lack of support, and being overweight. This may be due to a belief that exercise is beneficial for a wide range of health conditions and that few injuries would totally preclude some form of exercise. Although both male and female doctors saw time and motivation as the most important barriers, more female doctors perceived cost and ethnic/cultural background as significant. These are known factors but have received little real attention in existing strategies designed to promote exercise. Aside from recommending walking as a free activity and one that can save costs if undertaken as a form of transport, little has been done to address the financial impediments to participation in exercise. In summary, this is the first paper to demonstrate, among a large, population-based sample of Australian family physicians, the gap between the actual and the desirable frequencies with which family doctors advise patients regarding physical activity and to demonstrate that doctors’ low self-efficacy is a significant barrier to increasing the frequency with which effective advice on physical activity is provided to patients. Currently, family physicians do appear to be advising their patients to undertake the most popular form of exercise, namely walking, and are aware of the major barriers patients face in participating in physical activity. However, we found significant differences between current practice and perceived desirable practice in the promotion of exercise. Although family practitioners promote exercise to patients through verbal advice in the consultation, there is a need to provide the doctors and patients with written materials in a form that is useful, convenient, and of established effectiveness. Furthermore, FPs feel less confident giving patients specific advice on exercise. It appears that further skills, knowledge, and experience may be required if doctors are to give their patients more detailed, and potentially more effective, advice on exercise. Our results suggest the scope for referral systems in the promotion of physical activity to patients merits further
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exploration. Although a reduction in physical inactivity is now considered one of the ‘‘best buys’’ in public health care [51], there is still an urgent need for development, implementation, and evaluation of strategies designed to accelerate progress toward this goal and specifically to close the gap between what doctors are doing now and what they agree could and should be done in family practice.
16. Muir J, Mant D, Jones L, Yudkin P. Effectiveness of health checks conducted by nurses in primary care: results of the OXCHECK study after one year. Br Med J 1994;308:308–12.
ACKNOWLEDGMENTS
19. Hebert JR, Kristeller J, Ockene JK, Landon J, et al. Patient characteristics and the effect of three physician-delivered smoking interventions. Prev Med 1992;21:557–73.
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20. Jack BW, Gans KM, McQuade W, Culpepper L, Lasswell A, Hume AL, et al. A successful physician training program in cholesterol screening and management. Prev Med 1991;20:364–77. 21. Baron JA, Gleason R, Crowe B, Mann JI. Preliminary trial of the effect of general practice based nutritional advice. Br J Gen Pract 1990;40:137–41. 22. Copeman RC, Swannell RJ, Pincus DF, Woodhead KA. Utilisation of the ‘‘Smokescreen’’ smoking-cessation program by general practitioners and their patients. Med J Aust 1989;151:83–7. 23. Ornstein SM, Garr DR, Jenkins RG, Rust PF, Zemp L, Arnon A. Compliance with five health promotion recommendations in a university-based family practice. J Fam Pract 1989;29:163–8. 24. Jamrozik K, Vessey M, Fowler G, Wald N, Parker G, Van Vunakis H. Controlled trial of three different anti-smoking interventions in general practice. Br Med J 1984;288:1499–503. 25. Long BJ, Calfas KJ, Wooten WJ, Sallis JF, Patrick K, Goldstein M, et al. A multisite field test of the acceptability of physical activity counseling in primary care: project PACE. Am J Prev Med 1996;12:73–81. 26. Wood N, Whitfield M, Bailey D. How do general practitioners view their role in primary prevention. Health Educ J 1989;48: 145–9. 27. Orleans CT, George LK, Houpt JL, Brodie KH. Health promotion in primary care: a survey of US family practitioners. Prev Med 1985;14:636–47. 28. Bauman A, Mant A, Middleton L, Mackertich M, Jane E. Do general practitioners promote health?: a needs assessment. Med J Aust 1989;151:262–9. 29. Bruce N, Burnett S. Prevention of lifestyle-related disease: general practitioners’ views about their role, effectiveness and resources. Fam Pract 1991;7:373–7. 30. Bull FCL, Schipper ECC, Jamrozik K, Blanksby BA. Beliefs and behaviour of general practitioners regarding promotion of physical activity. Aust J Public Health 1995;19:300–4. 31. Sherman SE, Hershman WY. Exercise counselling: how do general internists do? J Gen Intern Med 1993;8:243–8. 32. Ruth D, Cockburn J, Farish S, Piterman L, McConachy M. General practitioners’ reported practices and beliefs concerning the prevention of cardiovascular disease: findings from a survey of Australian general practitioners. In: Doessel DP, editor. The general practice evaluation program: the 1992 work in progress conference. Part B. Canberra: Australian Association for Academic General Practice, 1993. 33. Reed BD, Jensen JD, Gorenflo DW. Physicians and exercise promotion. Am J Prev Med 1991;7:410–5. 34. Williford HN, Barfield B, Lazenby RB, Scharff-Olson M. A survey of physicians’ attitudes and practices related to exercise promotion. Prev Med 1992;21:630–6. 35. Risk Factor Prevalence Committee. Risk Factor Prevalence Committee Study: Survey No 3 1989. Canberra: National Heart
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44. Watkins CJ, Papacosta AO, Chinn S, Martin JA. A randomized controlled trial of an information booklet for hypertensive patients in general practice. J R Coll Gen Pract 1987;37:548–50. 45. Kushner RF. Barriers to providing nutrition counseling by physicians: A survey of primary care practitioners. Prev Med 1995; 24:546–52. 46. Mullen PD, Tabak ER. Patterns of counselling techniques used by family practice physicians for smoking, weight, exercise and stress. Med Care 1989;27:694–704. 47. Biddle SJH, Fox KR, Edmunds L. Physical activity promotion in primary health care in England: final research report. London: Health Education Authority, 1994. 48. Frank E, Kunovich-Frieze T. Physicians’ prevention counseling behaviours: current status and future directions. Prev Med 1995;24:543–5. 49. Lurie N, Slater J, McGovern P, Ekstrum J, Quam L, Margolis K. Preventive care for women—does the sex of the physician matter. N Engl J Med 1993;329:478–82. 50. Levy S, Dowling P, Boult A, McQuade W. The effect of physician and patient gender on preventive medicine practices in patients older than fifty. Fam Med 1992;24:58–61. 51. National Forum for coronary heart disease prevention. Physical activity: an agenda for action. London: Health Education Authority, 1995.
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
<0.0001 <0.0001 <0.0001
perceived desirable practice. Significantly more doctors indicated they should provide information on frequency (90%; x2 4 7.0, df 4 2, P 4 0.03), on intensity (87%; x2 4 20.0, df 4 2, P < 0.0001), and on duration (87%; x2 4 17.1, df 4 2, P 4 0.0002). The three barriers judged as ‘‘most likely’’ to affect a patient’s participation in exercise were lack of motivation, lack of time, and family commitments. Just over half of the doctors thought lack of support, lack of company, and being overweight were also likely to affect participation. Few doctors thought fear of injury (8%) and cost (16%) were important factors (see Table 5). We looked for any differences in perception of barriers to exercise between male and female doctors and younger and older FPs (controlling for age). Female doctors are significantly more likely to perceive cost (P < 0.0005), family commitments (P < 0.01), lack of time (P < 0.05), ethnic background (P < 0.05), and lack of confidence (P < 0.05) as barriers to participation than are male doctors (see Table 5). Younger male physicians (<35 years of age) are significantly more likely to perceive ‘‘too much effort’’ (x2 4 20.9, df 4 6, P < 0.005), ‘‘lack of time’’ (x2 4 15.8, df 4 6, P < 0.01), and ‘‘lack of confidence’’ (x2 4 14.7, df 4 6, P < 0.5) as important than do older doctors. Numerous small cells precluded statistical analysis of relationships across age for female physicians.
et al. [41] and Wells et al. [42], we found verbal advice to be the most frequently used technique. Less than 20% of the doctors almost always provided written information in the consultation and in the waiting room. This is despite evidence supporting the additional impact of written material when it is used to supplement verbal advice from doctors [43,44]. The infrequent use of written material may be due to its availability, accessibility, and practicability in the setting of family practice—just finding a pamphlet when it is needed can be difficult! Some doctors believe that pamphlets are ineffective and that patients do not use them [32]. Videos are used by few doctors and are not seen by many as a method that they should be using regularly. We did not explore whether this was due to concerns about establishing and running a system for lending videos to patients, about the availability and cost of videos, or about the proven effectiveness of videos as a method of promoting exercise to patients. In contrast, Kushner found that 50% of the 1,103 primary care physicians surveyed were interested in home video demonstration tapes [45]. Given the pressure on FPs to undertake opportunistic health promotion, we were interested in the current use of, and support of, referral systems as a method to promote exercise to patients. About 10% of doctors cur-
DISCUSSION
TABLE 3 Family Practitioners’ Confidence in Giving Advice on Physical Activity
We developed two questionnaires to assess current practice (do you) and perceived desirable practice (should you) in the promotion of physical activity by family practitioners. To avoid influencing self-report on current practice each doctor completed only one of these questionnaires. The credibility of our results was enhanced by including in the sample all family practitioners in the study area and by the corrected response fraction of 71%. It is acknowledged, however, that selfreports of usual practice are subject to error and may be biased in the direction of perceived desirable practice. This survey addressed the methods that doctors were currently using, or thought they should use, to promote exercise. Not surprisingly, and like Heywood
I feel able to give general advice on physical activity I feel able to give specific advice on physical activity
Disagree and strongly disagree (%)
Neither agree nor disagree (%)
Agree and strongly agree (%)
Malesa Femalesa Total
1.7 0.8 1.4
7.2 7.5 7.3
91.1 91.6 91.3
Males Females Total
17.1 34.7 22.4
31.5 33.3 32.2
51.4 31.7 45.5
a Denominators are: M 4 543; F4 239; values in the table are row %.
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BULL ET AL.
TABLE 4 Type of Physical Activity Recommended by Family Pactitioners Current practice (%) Type of excercisea Vigorous excercise Less vigorous exercise Physical activity apart from exercise Increase walking as part of daily activities Walking specifically for fitness a b
Desirable practice (%) b
M n 4 260
F n 4 130
Total n 4 392
M n 4 285
F n 4 110
Totalb n = 397
8.4 6.4 1.2 26.6 57.4
2.5 1.7 0 14.0 81.8
6.5 4.8 0.8 22.6 65.3
8.0 9.1 1.1 25.0 56.8
7.3 2.7 0.9 25.5 63.6
7.8 7.2 1.0 25.1 58.9
Repondents could choose only one activity; each column of figures totals 100%. Total may differ due to missing data on sex.
rently refer patients to fitness centers, less than 15% refer patients to qualified exercise personnel, and less than 1% refer to other staff in their practice. A similarly low use of referral systems has been found in other studies [27,41,46], although Biddle et al. [47] report greater use of referral, particularly to in-house programs, by FPs in the United Kingdom. Among Western Australian FPs there was considerable hypothetical support for ‘‘referral to qualified personnel’’ (47% agreed or strongly agreed) while almost a third supported ‘‘referral to fitness centers’’ (31% agreed or strongly agreed). Few supported referral to other staff in their practice which may reflect a reality that there is no one else in their practice with a special interest or skills in promoting or supervising exercise, that everyone else in the practice is as busy as they are, or that doctors are not comfortable referring to colleagues or to other staff within the practice. In the United States, Williford et al. [34] reports that 13% of physicians had staff members whom they indicated developed exercise prescriptions for their patients. An additional openended question found that the small number of doctors who did refer patients to other staff usually sent patients to physiotherapists or dietitians. Similarly, physiotherapists, dietitians, and community nurses received strongest in-principle support as sources of assistance, no doubt reflecting the established channels of referral between FPs and allied health professionals. However, this does raise the question of how much training and experience these professionals have in the promotion and supervision of exercise in otherwise healthy individuals. A ‘‘health promotion officer’’ was mentioned by only three doctors. Even so, the potential of referral systems for the promotion of physical activity should be explored. This survey found that doctors are more confident at providing general rather than specific advice on physical activity to patients. General advice is understood to mean that the doctor mentions to a patient the need to do more exercise but does not specify or discuss types of exercise, frequency of exercise, or how the patient might start increasing their level of exercise. Conversely, specific advice would involve a doctor provid-
ing these and possibly other details to the patient. Doctors could feel less confident about providing specific advice due to the following reasons: a lack of knowledge of the different options for exercise that are available and of which option would be most appropriate to the patient’s needs, a lack of skills and experience in counseling patients on exercise, a perception that lifestyle counseling is ineffective, a lack of time to provide specific advice, or a belief that patients are not interested in hearing advice on changing their lifestyle. Doubts TABLE 5 Family Practitioners’ Knowledge of Barriers to Adoption of Exercise 0Likely0 or 0very likely to affect0 (%)
Lack of motivation a,b Lack of time Family commitmentsc Lack of support from spouse/partner Lack of company to exercise with Overweight Existing illness or injury Small benefit for a lot of effortd Age Lack of confidencea,e Perceived unimportance of exercise Ethnic/cultural backgrounda Lack of knowledge/skills Insufficent access Costf Fear of injury a
Male n 4 545
Female n 4 240
Total n 4 789
90.5 87.3 72.9
91.5 93.3 84.4
90.8 89.1 75.9
53.5
62.0
56.3
54.8 54.3 46.3
59.7 46.9 51.4
56.1 51.8 48.2
42.5 41.7 37.2
39.8 37.6 47.7
41.9 40.2 40.0
39.1 32.8 37.9 28.0 12.1 8.1
40.0 48.6 28.7 34.1 23.9 6.2
39.5 37.5 35.0 30.1 15.5 7.5
Significant difference between male and female FPs (P < 0.05). Significant difference between younger male and older male FPs (P < 0.01). c Significant difference between male and female FPs (P < 0.01). d Significant difference between younger male and older male FPs (P < 0.001). e Significant difference between younger male and older male FPs (P < 0.05). f Significant difference between male and female FPs (P < 0.005). b
HOW CAN AND DO FAMILY PHYSICIANS PROMOTE PHYSICAL ACTIVITY?
about effectiveness of health promotion, lack of skills, and lack of time have been reported in other studies, both in the United States and in Australia [26–28,30– 32]. That some FPs perceive their patients as being not interested in changing their lifestyle is supported by our research on barriers to the promotion of exercise by doctors. As we have shown elsewhere, after ‘‘lack of time’’ and ‘‘lack of resources,’’ ‘‘patient preference for drug treatment’’ is identified by FPs as a barrier to their promoting physical activity more systematically [30]. Nevertheless family physicians do believe exercise is important and, in addition, they report that doctors should be advising all their patients more often than is currently occurring [30,33].These results concur the need for more skills and practice in counseling on exercise reported by both Williford et al. [34] and Sherman and Hershman [31]. We found that male FPs were more confident than female doctors in giving patients specific advice on exercise while there was no such difference in giving general advice on exercise. Other studies have shown differential rates of preventive practices between male and female physicians [48]. For example, female FPs are more likely to undertake screening via mammography and Pap smears than are their male counterparts [49,50]. The results from this study suggest that the content of advice on lifestyle risk factors may also differ between male and female physicians. It is possible that male doctors feel more confident about giving specific advice on exercise due to higher levels of participation in exercise, particularly vigorous exercise, themselves [35,36]. Alternatively, female practitioners may spend more time addressing the barriers to participation rather than the specific details of the type of exercise. This study did find differences between male and female FPs on their perceptions of barriers to exercise, which, if confirmed by further studies, may have important implications for the type of training that is offered to male and female FPs. Research now supports the message that a regular routine of 30 min of walking on most days of the week is sufficient to obtain the benefits to health afforded by exercise [1]. Walking was the form of exercise recommended most frequently by the male and female doctors completing this survey. Similarly, Ruth et al. [32] found that over 50% of doctors in the state of Victoria, Australia, suggested walking when presented with a specific case scenario. Advising patients on walking is consistent with population surveys that have found walking to be the most popular activity for adults wishing to take up (more) exercise [35–37]. We found no significant difference between the current frequency with which each type of exercise was recommended (do you) and the pattern of advice doctors thought represented perceived desirable practice (should you). However, there were differences between male and female doctors in the type of exercise they
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recommend to a sedentary adult that reflect population research showing that more men than women participate in vigorous exercise [35,36]. Not only are doctors recommending walking, an activity that just over 50% of Australian men and women undertake on a regular basis [35], but they are familiar with the common barriers to patients taking up exercise. Consistent with other reports, FPs in Perth perceived lack of time, lack of motivation, and family commitments as the constraints that most affect the adoption of exercise [36,38–40]. One exception was the doctor’s perception of injury as a barrier. In the Pilot Survey of the Fitness of Australians, injury was the third most frequently reported barrier cited by the public across all ages and in both men and women [35]. However, only 50% of the doctors in this survey felt injury to be important and it ranked seventh after lack of company, lack of support, and being overweight. This may be due to a belief that exercise is beneficial for a wide range of health conditions and that few injuries would totally preclude some form of exercise. Although both male and female doctors saw time and motivation as the most important barriers, more female doctors perceived cost and ethnic/cultural background as significant. These are known factors but have received little real attention in existing strategies designed to promote exercise. Aside from recommending walking as a free activity and one that can save costs if undertaken as a form of transport, little has been done to address the financial impediments to participation in exercise. In summary, this is the first paper to demonstrate, among a large, population-based sample of Australian family physicians, the gap between the actual and the desirable frequencies with which family doctors advise patients regarding physical activity and to demonstrate that doctors’ low self-efficacy is a significant barrier to increasing the frequency with which effective advice on physical activity is provided to patients. Currently, family physicians do appear to be advising their patients to undertake the most popular form of exercise, namely walking, and are aware of the major barriers patients face in participating in physical activity. However, we found significant differences between current practice and perceived desirable practice in the promotion of exercise. Although family practitioners promote exercise to patients through verbal advice in the consultation, there is a need to provide the doctors and patients with written materials in a form that is useful, convenient, and of established effectiveness. Furthermore, FPs feel less confident giving patients specific advice on exercise. It appears that further skills, knowledge, and experience may be required if doctors are to give their patients more detailed, and potentially more effective, advice on exercise. Our results suggest the scope for referral systems in the promotion of physical activity to patients merits further
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exploration. Although a reduction in physical inactivity is now considered one of the ‘‘best buys’’ in public health care [51], there is still an urgent need for development, implementation, and evaluation of strategies designed to accelerate progress toward this goal and specifically to close the gap between what doctors are doing now and what they agree could and should be done in family practice.
16. Muir J, Mant D, Jones L, Yudkin P. Effectiveness of health checks conducted by nurses in primary care: results of the OXCHECK study after one year. Br Med J 1994;308:308–12.
ACKNOWLEDGMENTS
19. Hebert JR, Kristeller J, Ockene JK, Landon J, et al. Patient characteristics and the effect of three physician-delivered smoking interventions. Prev Med 1992;21:557–73.
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