ReviewPhysical activity counseling in primary care: Who has and who should be counseling?
Introduction
Participation in regular physical activity has numerous physical and mental health benefits for healthy and diseased populations. These include improved cardiovascular health, lowered blood pressure, reduced risk of mortality, increased muscle strength, decreases in depression and anxiety, and improved quality of life [1], [2], [3], [4]. These findings have lead to multiple recommendations for physical activity that range from at least 30 min of moderate-intensity physical activity on 5 or more days of the week or 20 min of vigorous intensity on 3 or more days of the week [5] to 60 min of moderate-intensity physical activity everyday, specifically to prevent weight gain [6]. Despite these recommendations, only 21–26% of North Americans are sufficiently physically active to achieve optimal health benefits, and many are physically inactive [7], [8]. Simply said, without intervention, most people remain sedentary [9].
Primary-care settings and, more specifically, physicians have been targeted to assist in addressing the problem of inactivity by conducting assessments, counseling, and prescribing physical activity to their patients. It is not surprising that this avenue has been given attention due to the potential of primary care settings to reach a large majority of the population. For example, in 2001, 80–94% of North Americans met with a general practitioner and 24% had four to nine visits [10], [11]. Therefore, physicians are often a primary source of information regarding healthy lifestyle decisions [12], [13]. Moreover, patients identify them as credible sources for this information [12], [14]. As a result, visits to a physician provide an excellent opportunity for initiating physical activity counseling.
Without intervention, the rates of physician advice and counseling for physical activity are low. Only 28–34% of patients report receiving advice to increase their physical activity and, of those, most seem to be at higher risk of health problems [15], [16]. Further, analyses of audio-taped physician–patient interactions indicate that only 21% of patients are advised to be physically active [17]. However, 87% of physicians report that they frequently advise their patients to be physically active [18]. Clearly, there is a discrepancy between reported rates of advice given and received. As some authors have suggested, rates of counseling reported by physicians may be inflated because of small response rates and social desirability [19]. Another explanation may be that physicians see there patients many times a year and do not counsel on each occasion; audio-tapes at one time-point may not capture the counseling. Nonetheless, if physicians are effective at providing physical activity counseling, it appears that the advice rates are sub-optimal.
When physicians do ask or advise about physical activity, they often stop there. Only approximately 20% of physicians write physical activity prescriptions [18], [20] despite evidence suggesting that written prescriptions increase physical activity above and beyond verbal advice [21]. The question is—what stands in their way and what alternatives are there?
Physicians face numerous barriers that prevent them from counseling patients about physical activity. The most prevalent barrier is lack of time [22], [23], [24]. This challenge leads physicians to provide physical activity recommendations to patients already ill or of compromised health [25] rather than behavioral counseling for physical activity for primary prevention [16], [23].
If physicians did have the time, they may still be deterred from counseling because they often lack physical activity counseling skills, training, or knowledge [26], [27], [28]. Physicians report a perceived ineffectiveness in their counseling [28]. Only 5.3% of 200 Canadian physicians believed that they were able to successfully change patients’ physical activity behavior, and 15% considered themselves “not at all successful” [29]. Others report having limited medical school and residency training about the benefits of physical activity [30], [31] and inadequate knowledge of writing a physical activity prescription or referral [32]. Furthermore, only a minority of physicians are trained to provide structured counseling over several sessions [33]. Finally, barriers at the systems level (e.g., government and community) are also evident. Physicians have reported a lack of institutional support [34] and little or no reimbursement for their physical activity counseling efforts [24]. Exploring feasible alternatives to physician-only interventions is warranted.
Section snippets
Physical activity interventions
Despite these barriers, researchers recognizing the physician's credibility and potential to contact a large portion of the population have designed physical activity interventions in primary care settings aimed at increasing physical activity levels of patients. The impact of these interventions has been studied rigorously, and resulted in five published reviews in the past 5 years [34], [35], [36], [37], [38].
Overall, the results of these reviews are inconsistent with all presenting many
Intervention provider
A scarce amount of research has examined factors related to the type and appropriateness of the specific intervention provider. To date, interventions in the primary-care setting have been led by a multitude of providers alone or in collaboration, including physicians, nurses, and other allied health professionals such as health educators, exercise development officers, exercise physiologists, exercise specialists, exercise consultants, and dieticians/nutritionists. Considering the variability
Discussion
Overall, each of the intervention-provider formats generated some improvements in physical activity behavior. Yet, it appears that the combined-provider or allied professional only interventions produce the best results over time. Moreover, these interventions reduce time demands on physicians and provide specialized care necessary for physical activity maintenance. However, the reader is cautioned of this conclusion—it may not be as simple as who does the counseling, but the length, intensity,
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