How General Practitioners promote ‘lifestyle’ physical activity

Patient Education and Counseling 54 (2004) 101–106

How General Practitioners promote ‘lifestyle’ physical activity J. McKenna∗ , M. Vernon Department of Exercise and Health Sciences, University of Bristol, Tyndall Avenue, Bristol BS8 1TP, UK Received 15 September 2002; received in revised form 6 December 2002; accepted 15 June 2003

Abstract We investigated how General Practitioners (GPs) promote lifestyle physical activity (PA) (‘accumulate 30 min of at least moderate PA on 5 or more days per week’: PA30 × 5) to patients in the different stages of change, using a range of counselling strategies. These strategies included six ‘A’ factors (Ask, Assess, Advise, Assure, Arrange a follow-up, and Applaud). In a postal questionnaire (68% return rate), 47% of GPs from a single UK health district reported regularly promoting PA30 × 5. A stepwise logistic regression identified three counselling strategies that predicted regularly promoting PA30 × 5: (1) arrange follow-ups for patient pre-contemplators (OR = 4.93), (2) patient contemplators passed to GP exercise referral scheme (OR = 2.34), and (3) asking relapsers about their PA30 × 5 (OR = 2.61). GPs who regularly promote PA30 × 5 base their counselling on patients’ pre-existing PA behaviour, using ‘effortful’, ‘stage-matched’ approaches. Since these are acceptable to GPs, in-service training may build on using these three factors. © 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Physical activity; General Practitioners; ‘A’ factors; Stage of change; Counselling

1. Introduction

1.2. Activity counselling within General Practice

Understanding about the relationship between physical activity (PA), health and disease continues to expand [1]. Despite these developments, the majority of adult urban populations in the developed world remain sedentary, not least in the UK [2,3]. As a result, Public Health interventions to reduce the ill-health and disease caused by sedentary lifestyle have become widespread [4–8]. Although PA promotions within General Practice are central to this Public Health effort, these interventions show varied, and occasionally disappointing, outcomes [9–16]. These varying outcomes may reflect different PA messages, and different delivery styles.

As lifestyle activity can be based around walking, it may appeal to residents of poor neighbourhoods who are at the ‘wrong’ end of the social gradient for disease [21]. Walking is already included in up to 80% of doctors’ recommendations to increase PA [22], perhaps because it helps them to overcome problems in explaining the specifics of fitness-based prescriptions [22,23]. As such, the ‘lifestyle’ message is cheaper to deliver than ‘structured’ exercise prescriptions [24]. Thus, the PA30×5 message can be justifiably promoted by most, if not all, General Practitioners (GPs). However, it is unclear what proportion of UK GPs regularly promote any form of PA, including PA30 × 5. In England, almost 70% of GPs and Practice Nurses reported being regular PA promoters [25], versus 51% of New Zealand GPs [22]. Only 12% of US physicians were familiar with the ‘lifestyle’ message [26]. Low levels of patient recall (13–34%) [27–29] compound the shortfalls implicit to inconsistent or opportunistic delivery.

1.1. A new activity message Recent trials [17–20] confirm the acceptability and efficacy of a new PA message. This new message has shifted to ‘lifestyle’ activity, away from a concern for fitness. In ‘lifestyle’ activity, at least 30 min of at least moderate intensity PA, like brisk walking or digging the garden is accumulated on 5 or more days per week (PA30 × 5). ∗ Corresponding author. Tel.: +44-117-331151; fax: +44-117-331-1148. E-mail address: [email protected] (J. McKenna).

1.2.1. GP training in PA promotion For health professionals, recent in-service training in behaviour change is often based on theoretical models of how individuals achieve self-change. One such model is the Transtheoretical Model [30], which proposes that individuals are in one of five stages of change, depending on their

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readiness to behave differently. People in the inactive stages of Precontemplation or Contemplation have the greatest difficulty in changing their behaviour. They need support in developing a positive mind-set regarding PA. Infrequently active individuals are in the Preparation stage and particularly need help establishing regular PA involvement. People who are regularly and frequently active people are either in the Action or Maintenance stages and profit from support that enhances their ability to resist relapsing. Knowing the particular needs of people in the different stages allows counselling to be stage-matched. Studies of stage-matching have reported improved patient outcomes [31,32]. Stage-based approaches offer GPs a patient-centred protocol for counselling patients, which may make PA promotion more systematic. For UK health professionals this approach has been widely endorsed within in-service training during the 1990s [33]. The model has also been used to consider GPs’ readiness to undertake exercise promotion [25]. 1.2.2. The ‘A’ factor approach Another systematic, patient-centred counselling style that GPs may adopt to encourage PA to their patients, is the ‘A’ factor approach [34–36]. Here the different elements (e.g. Ask, Assess, Advise, Assure, Arrange a follow-up, and Applaud) are used to deliver behaviour change messages, beginning with asking, through to advising and then arranging follow-ups. With many possible combinations, the ‘A’ factors have been examined in PA promotion [37]. Most importantly, when GPs use the ‘A’ factors, patients remember it. When GPs used the ‘A’ factors, even though they had not been trained in this approach, 22% of their patients recalled being ‘assessed’, 16% ‘advised’, and 3% ‘assisted’, within the previous 3 months [38]. In another study, 28% of patients (n = 509 of 1818) reported being ‘advised’ about exercise, of whom 193 were ‘assisted’ to develop their exercise plan, and 214 attended ‘arranged’ follow-ups [39]. More impressively, 52% of over-50-year-olds recalled being ‘asked’ about exercise by their GP in their most recent appointment [39]. With appropriate in-service training, 83% of doctors talked about exercise in consultations and 99% of patients correctly recalled that counselling [37]. Furthermore, 63% of physicians reported that this counselling had little or no effect on length of office visits [37]. This helps to address the perception that there is too little time in consultations to promote PA. Given that GPs prefer to use multiple approaches to counsel behaviour change [15,37], these ‘A’ factors may replace, or become ‘blended’, with other routine promotional practices, including stage-matching. ‘A’ factors may even be used by staff who have not had specific, or even recent, in-service training in counselling [34]. However, little is known about how GPs promote the PA30 × 5 message, nor how the ‘A’ factors are used with patients in the different stages of change.

1.2.3. GP Referral schemes Since the late 1990s there has also been a massive expansion of GP exercise referral schemes in England [40–42]. In these schemes, GPs refer patients to exercise classes and specialist support outside the Practice. It is not clear which GPs support these services, nor for which patients. GPs who are discouraged from personally promoting PA may support these services. GPs are known to have barriers to PA promotion, including lack of time [25], feeling that they have only low skill in communicating about change, or having no formal protocol for delivery [43]. Others may supplement their counselling with referrals to these schemes. 1.3. Purpose The study had four main purposes: • To identify levels of PA30 × 5 promotion among GPs within a single Health Authority area. • To explore how the ‘A’ factors are emphasised in promoting PA30 × 5. • To identify levels of stage-matched promotion using the ‘A’ factors. • To identify how recent in-service training has influenced delivery.

2. Methods A five-section questionnaire was developed and refined. The finalised version achieved a Flesch–Kincaid score of 6.9, which indicates the number of full-time school years needed to understand the content. Section 1 identified personal and practice demographics. A definition of ‘lifestyle’ PA concluded this section. Section 2 addressed appointment duration, and GP stage of change for PA30 × 5 promotion. In piloting (n = 10) the 7-day test–retest reliability was r = 0.78. A further item assessed perceptions of how strong an effect GPs felt they had on changing their patients PA30 × 5 behaviour (1: not at all effective, 5: very strong effect). The final item asked GPs to estimate the percentage of sedentary patients on their Practice list who they felt could benefit from becoming, or continuing to be, more active. Section 3 assessed the strategies especially emphasised with patients in each of the five stages of change. The same question format was used for patients who had relapsed from an active stage of change. Six ‘A’ factor options were offered (Ask about, Advise to, Assure that, Assist to, Arrange follow-up, Applaud changes), plus pass to a GP-referral scheme, and none of these. In piloting (n = 10), the agreement of responses 7 days apart averaged 75%. The final item recorded three estimates of their Practice population. With an instruction to achieve a total of 100% for the three responses, GPs estimated the percentage of their patients who they felt (1) were lifestyle active, and (2) who were not, plus (3) a don’t know option.

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Section 4 reported the hours spent in different types of activity promotion training within the past 5 years. Three choices were also offered: (1) helping people change course, (2) motivational interviewing training [44], and (3) other. Questionnaires were distributed in two mail-outs with a stamped addressed envelope for returns, to every GP within a single Health Authority—Wiltshire—in southern England. The study was approved by the local NHS Ethics Committee. 2.1. Analysis All analyses were conducted using the SPSS software package. Univariate analyses were conducted after data screening. Consistent with McKenna et al. [25], logistic regression was used to predict the stage of change for promoting the PA30 × 5 (non-promoters ‘0’: Precontemplation, Contemplation and Preparation; promoters ‘1’: Action and Maintenance) using the ‘A’ factors that differed in univariate analyses.

3. Results 3.1. Response rate A sample of all 333 GPs in this health authority were mailed the confidential questionnaire. A response rate of 70% (n = 234) was achieved (94 (40.2%) female), representing a combined patient list of 746,010 from 90 different practices (Table 1). Table 2 shows the ‘A’ factor responses. 3.2. Level of PA30 × 5 promotion 47.1% of responding GPs were regularly and actively promoting PA30×5 (Action = 19.9%, Maintenance = 23.9%). The remainder were in the inactive, or irregular, promotion stages (Precontemplation = 5.3%, Contemplation = 9.2%, Preparation = 38.3%, Missing = 12%). Promotion was unrelated to recent in-service PA training, and only 28 GPs reported attending such training within the past 5 years. Only one estimate of the PA behaviour of Practice population differed according to GP stage for promoting PA30 ×

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Table 1 GPs personal and practice demography and estimates of effects of activity promotion on patients Mean (S.D.) GP demographics Age Years as a GP

43.6 (8.0) 13.7 (7.9)

Practice demographics No. of GPs in Practice No. of Patients on Practice List Consultation time (min)

4.8 (1.9) 8289 (3990) 9.55 (1.9)

Responses of patients to GPs activity counselling Percentage of patients (0 to 100%) responding positively to activity promotion Strength of effects on changing patients lifestyle activity (1: none, 5: very strong) Estimates (%) of patient behaviour (invited to achieve a sum of 100%) Who were not PA30 × 5 active (%) Who were PA30 × 5 active (%) Whose PA30 × 5 activity was not know (%)

Median 43 13 5 8500 10

45.2 (24.6)

50

2.58 (0.5)

3

47.3 (29.8) 18.4 (14.9) 34.3 (36.1)

50 20 20

5 (P < 0.05). This was the estimate for the proportion of patients who were lifestyle active. Estimates increased sequentially, beginning with a mean estimate of 8% for Precontemplator-GPs, rising to 15% for Preparer-GPs, and peaking at 25% in Maintainer-GPs. Although not significant, 54% of Precontemplator-GPs reported that they ‘don’t know’ their patients’ lifestyle behaviour, compared with 42% of Preparer-GPs and 25% of Maintainer-GPs. GPs also estimated that up to 1 in 2 of their patients could gain from becoming more lifestyle active. 3.3. ‘A’ factors in promoting PA30 × 5 GPs averaged 12 ‘A’ factor endorsements from a possible 48 (8 options × 6 stages). Table 2 shows the ‘A’ factors most emphasised with patients in the different stages of

Table 2 Numbers of GPs who reported emphasising counselling practices for patients in different stages of change (and in relapse) for PA30 × 5 Patient in this stage of change

Promotion category (n) Ask

Advise

Assure

Assist

Arrange

Applaud

Referral

None of these

Precontemplation Contemplation Preparation Action Maintenance Relapsea

111 72 62 53 51 73

151 113 91 35 14 119

16 41 53 81 88 7

43 80 79 13 8 85

19 31 30 11 9 37

39 57 102 166 161 19

20 55 61 12 1 47

6 4 2 2 8 3

405 453 480 373 340 390

Total

422

523

286

308

137

544

196

25

2441

GPs could report as many responses as were appropriate. Italicised figures indicate the highest levels of response for each stage. a Relapse is not formally a stage, but an intermediary between stages.

Total responses

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change. With inactive patients the most commonly endorsed factor was Advise (523 endorsements). Applaud (544 endorsements) was most emphasised with active patients. GP Referral was most strongly favoured for patients in Preparation. 3.4. Using ‘A’ factors to predict level of PA30 × 5 promotion Of the 48 counselling responses, univariate analyses identified six responses that distinguished different levels of promoting PA30 × 5: (1) Assist—Precontemplator patients, (2) GP Referral—Contemplator patients, (3) Assist— Maintenance patients, and Relapse patients (4) Ask, (5) Assist and (6) Arrange. To identify the most powerful predictors of the GP’s level of promotion, these were entered into a forward stepwise logistic regression of dichotomised stage (‘0’: Precontemplation, Contemplation and Preparation, ‘1’: Action and Maintenance). This analysis yields OR, which show the predictive value of endorsing a particular counselling strategies. The resulting three-step model correctly identified 66% of GPs, χ2 (3) = 23.92, P < 0.001. Step 1 included arranging follow-up meetings with Precontemplation patients, OR = 4.93 (95% CI 1.51–16.04). Step 2 identified passing Contemplators on to a GP Referral scheme, OR = 2.34 (95% CI 1.19–4.58). The final step identified asking relapsed patients about their lifestyle PA, OR = 2.61 (95% CI 1.40–4.86).

4. Discussion and conclusion This is the first study that centres on how GPs report promoting the ‘lifestyle’ activity (PA30 × 5) message in the UK. A further unique feature is the exploration of links between the three theoretical perspectives; (1) ‘A’ factors, (2) patient stage of change, (3) GP stage of change for promoting PA30 × 5. Clearly, different ‘A’ factors were emphasised with patients in the different stages. This equates to ‘stage matching’. As their preferred options, GPs may feel that these elements are especially powerful (though this is not explored here). Further, these practices were developed independently of recent in-service training. Almost 50% of GPs reported regularly promoting PA30× 5, suggesting rapid penetration of this message into daily practice. In 1997, 70% of GPs in the nearby geographical area of Avon, were ‘active promoters’ (the specific PA message was unreported) [25]. It is unclear whether this represents a temporal decline in levels of promotion or different levels of penetration for different activity messages. Compared with Precontemplator-GPs, the most active promoters reported treating up to three times more patients who were lifestyle active. They also knew the PA30 × 5 behaviour of more of their patients (3 in 4), compared with Precontemplator-GPs (1 in 2). These are the first

such estimates from GPs. The contrasts may indicate that non-promoters feel overwhelmed by the scale of the task among their patients. Alternatively, they may not appreciate the extent of sedentary lifestyle among their Practice population. Prospective studies will clarify whether these different estimates reflect either effective practice or unmet need. With inactive patients, GPs emphasised Advising about lifestyle activity. In contrast, with the active patients they Applaud their change efforts (Table 2). Perhaps reflecting limited local availability, fewer than 50% of the GPs Pass patients on to a GP exercise referral scheme. This service was most commonly reported for patients in the Preparation stage, though using it with Contemplator patients was a powerful predictor of the GPs level of promoting PA30 × 5. Stage-matching literature [30–32] suggests that this may be too much action for Contemplators who have not yet taken the decision to become more active. However, GPs may be using this approach in the understanding that they represent the first steps in becoming more active. Subsequent studies may explore which Contemplator patients capitalise on this referral process. All ‘A’ factor differences were independent of recent training. With clear differences according to the patients’ stage of change, this may explain why controlled trials of delivery style may produce equivocal PA outcomes [9–16]. Even after randomisation and training both groups may be delivering ‘tailored’ messages. The levels and intensity of PA promotion may reflect GPs’ perceptions of their effectiveness in changing patients’ behaviour. In one recent US study [29], family doctors emphasised three ‘A’ factors with older, female patients; ‘advice’, ‘arrange follow-ups’ and ‘assist to develop an exercise plan’. However, only 3% of these UK GPs felt they had a ‘strong’ effect on changing patients PA30 × 5 behaviour. This may represent a significant underestimate of their actual impact on patient behaviour, particularly since most reported using combinations of ‘A’ factors with patients in the different stages. Such combinations have been shown to influence behaviour change in other populations. US patients were more likely to be active if they reported that their GP combined (1) ‘advice’ to become more active, with (2) ‘arranging’ follow-ups (OR = 1.83) [29]. Among older patients (≥50 years), just ‘asking’ about PA increased the likelihood of their being active (OR = 1.7) [39]. Arranging a follow-up to discuss Precontemplator patients’ PA30 × 5 behaviour was the most powerful predictor. Emphasising this factor increases the chances of GPs reporting regularly promoting PA30 × 5 by almost five times (OR 4.93). Since patients in Precontemplation face the greatest challenge in changing, this suggests that these GPs are willing to undertake ‘effortful’ promotion. The other two factors were Pass the patient on to a GP Referral scheme (Contemplator patient), OR = 2.34, and Ask about the patient’s lifestyle activity (Relapsed patient), OR = 2.61. The tripartite model shows that GPs are integrating

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‘exercise on prescription’ schemes into their promotional efforts, where they are available. It also suggests that ‘Promoters’ actively track their patients’ PA progress, especially those patients in Precontemplation and Contemplation who have the greatest problems with change. 4.1. Limitation The study must be seen in terms of strengths and limitations. With a high return rate, higher than many published examples within General Practice, the study allows generalisability to the relationships of the different variables. On the other hand, the study relies on cross-sectional self-report. Subsequent studies will explore the relationship of self-report, observed behaviours, and patient recall. Longitudinal studies of change in professional practice are also needed. Finally, the dichotomisation of stage of change responses for promoting PA30 × 5 may be too rigid to reflect the dynamics of practice consultations. This work focuses on the level and style of PA30 × 5 promotion. GPs may be endorsing other PA messages, perhaps based on their own interests [25,45] or to meet a particular patient’s needs. Such promotions could include weight training or specialised prescriptions [45]. Exploring how GPs promote these different messages may help to improve understanding of GP decision-making and effectiveness. 4.2. Practice implications Although these cross-sectional data cannot address change, the logistic regression offers a possible agenda for local GP training. Given the lack of recent training, these counselling preferences may be particularly amenable to integration within daily practice. Stage-based understanding endorses behaviour change as a process; to reflect this GPs may need to adopt a similarly systematic, process-based approach to promoting PA30 × 5. Instead of training GPs to use all ‘A’ factors, the three significant predictors of active promotion could be used, since these are likely to reflect the experiences of GPs about ‘what works’ in their Practices and with their patients.

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Acknowledgements [19]

Our thanks go to the respondents and to Wiltshire Health Promotion Service for supporting this research. Also thanks to Professor Ken Fox, Mark Davis and two anonymous reviewers for helpful comments in developing this paper.

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