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Active Health Care Providers’ Practices and Views on Counseling Patients to be Active

Das, Bhibha M.; DuBose, Katrina D.; Peyton, Alexandra

Translational Journal of the American College of Sports Medicine: December 15, 2018 - Volume 3 - Issue 24 - p 190–195
doi: 10.1249/TJX.0000000000000075
Original Investigation
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ABSTRACT It is of public health importance to identify strategies for increasing U.S. physical activity levels because of the strong relationship between physical activity and health. One strategy is by having health care providers prescribe physical activity to their patients. The purposes of this study were to assess health care providers’ physical activity levels, to evaluate knowledge of benefits of physical activity, to examine barriers to counseling physical activity to patients, and to determine whether a relationship exists between health care providers’ physical activity levels and barriers to physical activity counseling. Health care providers (N = 30) wore an accelerometer for 1 wk and completed the International Physical Activity Questionnaire and a physical activity counseling questionnaire. Ninety-three percent of providers met physical activity guidelines. Only 7% of providers reported knowing physical activity recommendations; however, 87% reported providing physical activity counseling to patients. The benefits of physical activity reported were maintaining overall health and reducing the risk for disease development. The physical activity counseling barriers reported were lack of time and patient interest. Among this active sample of health care providers, personal activity habits did not influence physical activity promotion practices with patients. The main physical activity counseling barriers reported were lack of time and lack of patient interest. More research is needed to determine whether this finding and the barriers of time and the perception of lack of patient interest persist among providers who are not as physically active. From a translational perspective, health care providers should be educated to promote physical activity for their patients. These education opportunities should occur through professional coursework and continuing education credits.

Department of Kinesiology, East Carolina University, Greenville, NC

Address for correspondence: Bhibha M. Das, Ph.D., M.P.H., Department of Kinesiology, East Carolina University, 172 Minges Coliseum, Greenville, NC 27858 (E-mail: dasb@ecu.edu).

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INTRODUCTION

There is a well-established, dose–response relationship between physical activity and mental and physical health (1). Individuals with an active lifestyle, on average, live healthier, longer, and more productive lives than their inactive counterparts (2). Regular physical activity can prevent and manage numerous chronic diseases, including cardiovascular disease, diabetes, and some cancers (2). Notably, being active reduces one’s risk of all-cause mortality (3).

Despite the overwhelming evidence that physical activity is beneficial for maintaining mental and physical health (4,5), a significant proportion of the U.S. population does not meet current physical activity guidelines (6). One reason for this potential gap between theory and practice may be the lack of physical activity prescription by health care providers to their patients. Although health care providers often prescribe pharmaceutical interventions to prevent and manage chronic conditions, physical activity often is not prescribed as one such intervention (7,8). Evidence confirms physical activity can provide prescriptive value (9,10); however, very few health care providers use physical activity prescriptions. Furthermore, one of the objectives of Healthy People 2020 is to increase physical activity counseling by health care providers (11). As such, the Exercise is Medicine (EIM) initiative, a joint collaboration between the American College of Sports Medicine and the American Medical Association, recommends the prescription of physical activity as a method to improve patients’ health status (12). Moreover, the EIM initiative recommends health care providers assess each patient’s physical activity habits at every clinical visit as a vital sign (e.g., blood pressure and weight) (13). EIM recommends that health care providers use this information to determine the appropriate physical activity prescription for each patient, rather than providing a blanket recommendation.

A paucity of research exists examining the physical activity counseling behaviors/practices in health care providers, particularly as much of the research surrounding physical activity counseling has been done in physicians and not in health care providers as a whole. As such, it is imperative to understand not only the barriers health care providers face in prescribing physical activity but also their physical activity practices. Once these practices and barriers are understood, strategies for improving physical activity discussion between health care providers and patients may be developed. The purpose of this pilot study was to examine health care providers’ barriers to prescribing physical activity to their patients. A secondary purpose was to examine the relationship between health care providers’ physical activity levels and barriers they face with physical activity counseling.

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METHODS

The participants (N = 30) in this study were healthy male and female volunteers with an occupation falling under those considered a health care provider, which was limited to physicians, physician assistants, nurses, and nurse practitioners. To participate, the health care providers needed to directly prescribe medicine to patients and be at least 22 yr of age. Participant recruitment was done through flyers, social, media, and word of mouth. Flyers were placed throughout the community and also at local doctors’ offices, clinics, and hospitals. Thirty-two individuals expressed interest in the study. Two individuals were not eligible as their highest level of education was a bachelor of science in nursing; thus, they were unable to prescribe medication to participants. There were 30 participants enrolled in the study: 16 physicians, 6 physician assistants, 2 certified registered nurse anesthetists, and 6 nurse practitioners. For the physicians, 6 were pediatricians, 5 were general practitioners, 2 were radiologists, 1 was an occupational medicine specialist, 1 was an obstetrician/gynecologist, and 1 was an urologist. The university’s institutional review board approved this study protocol, and the health care providers completed informed consent before study activities.

At the first visit, participants completed an online demographics questionnaire and short version of the International Physical Activity Questionnaire (IPAQ) via Qualtrics, an online survey distribution tool (Qualtrics, 2016, Provo, UT). Participants also were measured for height (cm) with a portable stadiometer (model #IP0955; Invicta Plastics Limited, Leicester, UK) and weight (kg) with a portable electronic scale (model # 68987, Befour Inc., Saukville, WI). Then participants were given an accelerometer, accelerometer instructions, and an accelerometer wear log. Participants’ physical activity levels were measured over the course of 1 wk (7 d). Once the week’s physical activity monitoring period was completed, participants were asked a series of questions regarding the perceived benefits and barriers to prescribing physical activity to their patients.

Health care providers’ physical activity level was assessed over a 7-d period using a New Lifestyles NL-1000 accelerometer, which uses a piezoelectric accelerometer strain gauge to measure step counts and compute moderate-to-vigorous physical activity (MVPA) time. Validity of step counts obtained by NL-series accelerometers has been demonstrated with middle aged and older populations (14).

The IPAQ English short last 7-d self-administered format, which is validated for use in young and middle-aged adults (15–69 yr), was also used to measure the health care providers’ physical activity levels (15). The reliability of the IPAQ short self-administered version is 0.75, and the validity is 0.30 (15). The IPAQ asked about three specific types of activity undertaken in the following four domains: (a) leisure time physical activity, (b) domestic and gardening (yard) activities, (c) work-related physical activity, and (d) transportation-related physical activity (15). To calculate the participants’ walking MET-minutes per week, moderate MET-minutes per week, and vigorous MET-minutes per week, the IPAQ short version guidelines were used (15). Total MET-minutes per week was the sum of these three scores. A categorical physical activity score was also calculated to classify the health care providers into the following groups: inactive, minimally active (meets minimal physical activity recommendations), and HEPA (exceeding minimal physical activity recommendations) (15).

A modified version of the Karvinen et al. (16) questionnaire was used to assess physical activity counseling barriers faced by health care providers. This questionnaire was modified because Karvinen et al. (16) aimed to identify oncologist barriers to recommending physical activity to patients with breast cancer, whereas the current study aimed to identify barriers health care providers face when prescribing to any patient. There were two major questions assessed and each of these questions contained eight subgroups. The first eight subquestions assess the health care providers’ perceived benefits physical activity has for patients. The second set of questions queries the health care providers’ barriers to counseling and prescribing physical activity to patients. The health care provider’s responses to each question were given on a 5-point Likert scale ranging from 1 (not at all) to 5 (very much).

Descriptive data were calculated for the demographic variables, including age, sex, occupational category, work setting, years worked, and physical activity from the IPAQ and accelerometer (steps and MVPA minutes). Mean and SD values were calculated for each possible benefit physical activity has for patients and the health care provider’s barriers for recommending physical activity to patients. Frequencies were calculated for health care providers’ knowledge of physical activity recommendations, amount of training received for physical activity prescription, and amount of physical activity prescription that health care providers complete with patients. A Pearson’s correlation was used to examine the relationships between health care providers’ physical activity promotion practices, health care providers’ physical activity level (from IPAQ and accelerometer), perceived physical activity benefits, and physical activity promotion barriers. Statistical analysis was completed using SAS (version 9.3, Research Triangle, NC) and the alpha level was set a P < 0.05.

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RESULTS

The majority of participants were females (70%), Caucasian (73%), overweight (BMI = 26.3 ± 4.9 kg·m−2), and physicians (53%). The health care providers worked in a variety of settings (27% clinic, 20% physician’s office, 27% hospital, and 27% other setting), and 50% had been a health care provider for 1 to 15 yr and 47% for more than 16 yr.

Overall, the health care providers were very active. Table 1 shows the physical activity recorded from the accelerometer and the reported time spent in physical activity from the IPAQ. Overall, the health care providers accrued a little over 9000 steps per day; of those steps, 28.6 min·d−1 (~3 h·wk−1) was spent in MVPA as measured by the accelerometer. By contrast, based on data from the IPAQ, the health care providers reported spending more time in physical activity. Over 4 h·wk−1 was spent walking and 9 h·wk−1 was spent in all types of physical activities. To further underscore the high activity level of the participants, only 7% were inactive, 57% were minimally active, and 37% were considered HEPA (data not presented).

TABLE 1

TABLE 1

Table 2 shows the health care provider’s perceptions of benefits of physical activity to patients and the barriers to physical activity counseling. The health care providers viewed physical activity as having many benefits for their patients. The top two benefits identified were maintenance of overall health and reducing risk of disease development. These were followed by improving mental health and coping with stress. Although health care providers understand the value of physical activity, they identified specific barriers to prescribing physical activity to their patients. The top two barriers for discussing physical activity with patients were lack of time for counseling by health care providers and lack of patient interest. Frequency analysis indicated that for 50% of the health care providers lack of time was a major barrier for physical activity counseling (with a score ≥ 3). There was also a perception by the health care providers that patients were not interested in physical activity (44% with a score ≥ 3). Unsure what physical activity to recommend was the third highest barrier reported. Lack of reimbursement, safety, and effectiveness concerns were not reasons why health care providers would not talk to patients about physical activity.

TABLE 2

TABLE 2

The health care providers’ knowledge of physical activity recommendations was limited, only 2 (7%) indicated that they knew the recommendations, the majority (67%) had a limited knowledge, and 8 (27%) did not know the physical activity recommendations (data not shown). Most health care providers did not have any training related to physical activity (83%), and 77% indicated that they had an average to poor knowledge on how to prescribe exercise to patients. Even with this lack of knowledge, only 3% of health care providers indicated that they never ask a patient about their physical activity levels; 53% indicated they asked on most visits and 37% on some visits. Further, health care providers were also counseling patients on physical activity levels. Eight-seven percent of health care providers reported counseling patients about physical activity at least 50% of the time. Aerobic activities were recommended the most by the health care providers (57%), but other types of activity like lifestyle activities 20% and a combination of aerobic, resistance, and lifestyle activities (20%) were also recommended.

Bivariate correlations for health care providers’ physical activity promotion practices, physical activity level, benefits of physical activity for patients, and barriers for physical activity promotion are presented in Table 3. Overall, the health care provider’s physical activity level was not related to their physical activity promotion practices. This finding was found when steps per week (r = 0.12, P = 0.54), MVPA minutes per week (r = 0.12, P = 0.52), and total physical activity minutes from the IPAQ (r = 0.01, P = 0.95) were used. The health care provider’s physical activity promotion practices and physical activity levels were not related to either physical activity benefits or barriers. The physical activity benefits of maintaining health, improving mental health, and attenuating physical declines were positively related with improving activities of daily living and coping with stress (P < 0.05). The barrier of being unsure what to recommend for physical activity was inversely related with the physical activity benefits of attenuates physical declines, improves activities of daily living, and improves coping with stress (P < 0.05). The barrier of being unsure what to recommend was positively related with being unsure of the effectiveness of physical activity for patients (P < 0.05). Further, the barrier of lack of patient interest was positively related with the barrier of physical activity counseling not being reimbursed (P < 0.05).

TABLE 3

TABLE 3

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DISCUSSION

The most pertinent finding from this exploratory study is that despite only 7% of providers knowing physical activity recommendations, 87% of providers offered some form of physical activity counseling to their patients. Further, the counseling was primarily about aerobic (57%), but not resistance activities (3%). The lack of knowledge about physical activity recommendations and exercise prescription is consistent with what others have reported within the U.S. medical school and other health professions curriculum (17–20). This finding demonstrates the critical need for physical activity education in training and continuing education programs not only for physicians (21–23) but also for all health care providers (19,20).

Another notable finding was that health care providers’ physical activity level had no relationship to their promotion of physical activity for their patients. This finding contradicts a study by Frank et al. (24) where it was determined U.S. medical students who were active were more likely to provide physical activity counseling for their patients (24). Furthermore, others have demonstrated physicians’ personal physical activity habits influenced their attitudes of the benefits of physical activity (7,16,25). One reason for the difference in results may be the activity levels of the sample. In the current study, 93% of the health care providers met physical activity recommendations, which is higher than what has been previously reported (7,16,26).

Lack of time has been reported as a common barrier to physical activity counseling among physicians (16,25,27,28). The results of this study also found that lack time was the main barrier for physical activity counseling among health care providers. The perception that the patient was not interested in physical activity was another significant barrier reported in the current study. This barrier is similar to what oncologists have reported (16,29). One potential strategy to reduce the barrier of lack of time for health care providers may be through reimbursement of physical activity counseling. It is notable to mention that reimbursement did not play a role in physical activity counseling but lack of time did. It may be meaningful to examine if providers would find time, thus eliminating the lack of time barrier, to counsel patients on physical activity if counseling were reimbursed by insurance.

Interestingly, a lack of physical activity recommendation or referral knowledge and lack of reimbursement were not considered barriers among health care providers. Previous research has indicated that these are reported physical activity counseling barriers among physicians (8,18). The majority of research on physical activity promotion barriers has focused on physicians, given the positive influence different types of health care providers have on a patient’s health a better understanding of the physical activity promotion barriers for different types of health care providers is warranted.

One of the most pertinent strengths of this study is the use of objectively measured physical activity along with a questionnaire; most studies have only used subjective data (16,25). Second, this study included all health care providers (e.g., doctors, physician’s assistants, etc.), whereas other studies have simply analyzed only physicians’ barriers and physical activity levels (16,25). Of the 30 participants in this exploratory study, 14 were nonphysicians. Of the 14 nonphysicians, 12 were either physician assistants or nurse practitioners. As there is a shortage of primary care physicians in the United States (30), more and more allied health professionals such as physician’s assistants (31,32) and nurse practitioners (30) are taking on the role of providing primary care to patients. Therefore, including these primary care providers in the study strengthened the findings and advanced the field of prescribing physical activity. In addition, to the authors’ knowledge, no study has examined the relationship of the physical activity behaviors of nurse practitioners’ and physician’s assistants in relationship to their prescription of physical activity to their patients. Therefore, this study is particularly novel as it provides some of the first data examining this relationship, which may be more meaningful as more patients see nurse practitioners and physician’s assistants as their primary care providers. Future studies should examine these results by health care provider types to develop a better understanding of the relationship between providers’ physical activity levels and their prescription of physical activity to patients.

Although there are significant strengths to the study, there are several limitations. First, future research should include an overall larger sample along with a larger sample of each type of health care provider to examine if there are differences in physical activity counseling by provider type. As there are differences in specialties, types of visits conducted, and scope of practice among the health care providers examined, incorporating a larger sample along with a larger sample of each type of health care provider may provide more meaningful findings that may be translated into real-world applications.

Second, this sample of health care providers was active with only 7% of participants being classified as inactive. As such, future research should survey health care providers with a wider range of physical activity levels to further delineate if there are any relationships between physical activity counseling and levels, including inactive. In addition, the authors, because of the nature of the objective measurement device, were unable to parse out the percentage of physical activity related to occupational activities versus dedicated physical activity for leisure, transportation, or nonoccupational activities. Thus, future research should examine health care providers’ occupational physical activity versus nonoccupational physical activity. Furthermore, although one of the more notable findings is that reimbursement did not factor into physical activity counseling but lack of time did, it may be meaningful to determine whether providers would find the time to counsel patients on physical activity if this activity were reimbursed. As such, researchers should further examine this nuance. Finally, because this study focused on physical activity levels, there may have been a selection bias as only active individuals may have been interested in the study.

This study’s findings have significant practical implications. Foremost, as only 7% of health care professionals were aware of physical activity guidelines, it is imperative for health care training programs to incorporate this information into the coursework. It is not enough, however, to include this information into the curriculum. Accrediting agencies must also include this information on tests for licensure. In addition, this study’s findings highlight a novel partnership between the field of medicine and physical activity professionals. Findings demonstrate that although 7% of health care providers are aware of physical activity guidelines, 87% of health care providers reported counseling patients about physical activity at least 50% of the time. Because the majority of health care providers are unaware of physical activity guidelines but still prescribing physical activity, there may be misinformation being offered to patients, who view health care providers as experts on physical activity. As such, medical practices should work with physical activity professionals to provide expert information to patients on physical activity, including recommendations, goal setting, and overcoming barriers. As health care providers are often pressed for time and cannot adequately provide information due to time constraints and lack of knowledge, working with physical activity professionals may remove some of these barriers to physical activity counseling of patients.

In conclusion, among this sample of active health care providers, their personal physical activity behaviors did not influence their physical activity promotion practices with their patients. Although the majority of health care providers did not know current physical activity recommendations, they still counseled patients on engaging in physical activity. A better understanding of the physical activity promotion practices among different types of health care professionals is needed. Moreover, additional research is warranted to determine the role personal physical activity behaviors have on physical activity counseling among providers with a diverse level of physical activity.

The results and views of the current study do not constitute endorsement by the American College of Sports Medicine.

There are no financial or other contractual agreements that might cause conflicts of interest or be perceived as causing conflicts of interest impacted this work. There was no financial support for the work described in the article.

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