Family Practice Vol. 16, No. 3, 250-254
© Oxford University Press 1999
Increasing population levels of physical activity through primary care: GPs' knowledge, attitudes and self-reported practice
Bradford Health Authority, New Mill, Victoria Road, Saltaire, Bradford BD18 3LD,
a Division of Public Health, Nuffield Institute for Health, University of Leeds and
b Yorkshire Primary Care Research Network, Centre for Research in Primary Care, University of Leeds, Leeds, UK.
Lawlor DA, Keen S and Neal RD. Increasing population levels of physical activity through primary care: GPs' knowledge, attitudes and self-reported practice. Family Practice 1999; 16: 250–254.
Received 16 July 1998; Revised 18 November 1998; Accepted 28 January 1999.
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Abstract |
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Background. GPs have the potential to increase population levels of activity and thus produce important health gains.
Objectives and methods. The aim of this questionnaire survey was to determine the knowledge, attitudes and self-reported practice of GPs towards promoting regular physical activity and to assess the likely impact of GPs on population levels of physical activity.
Results and conclusions. A high response rate to the questionnaire was obtained and the results suggest that GPs have a good level of knowledge of the health benefits of regular physical activity and the levels required to achieve these, but do not promote activity in a way that will have an impact on the population level.
Keywords. General practice, health promotion, physical activity, population approach.
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Introduction |
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Regular physical activity is associated with positive health gain1,2 and it has been suggested that promoting physical activity is "public health's best buy".3 Although a population approach to promoting physical activity is appropriate, since the mean level of activity in the population is below that required for health benefit,4 ‘exercise on prescription schemes’ are the commonest physical activity intervention in primary care.5 These schemes adopt a high-risk approach and do not have a population impact.6 It has been suggested that GPs are in a good position to influence population levels of activity because of their access to most members of the population,7,8 because 90% of the population consult their GP at least once every 3 years9 and because in other areas of lifestyle behaviour change, notably smoking, GP advice has been shown to have a small but important impact on the population.10,11
There is very little evidence, from the UK, on effective ways to increase regular physical activity levels in healthy individuals.12 Little is known of UK GPs' attitudes towards promoting physical activity. It has been suggested that GPs have insufficient knowledge about the health benefits of regular activity to be able to give effective advice.13 The aim of this study is to determine the knowledge, attitudes and self-reported practice of GPs towards promoting regular physical activity and to assess the likely impact of GPs on population levels of physical activity.
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Method |
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Following a pilot study, a questionnaire survey was mailed to all 235 GPs (from 95 practices) in the Bradford district in May 1997. A second personalized reminder was sent to non-responders in June, followed by a telephone reminder in July.
GPs' attitudes and self-reported practice were assessed by a number of statements using a four-point Likert-type scale. The scores had no neutral points, forcing a choice for each statement. Knowledge was assessed by asking responders to indicate whether evidence of benefit, from regular physical activity, existed for each of a list of conditions; for this question a ‘don't know’ option was available. For most of the conditions listed, good evidence exists of a beneficial effect. In addition, two conditions (Alzheimer's disease and breast cancer) were included as ‘red-herrings’.
Data from returned questionnaires was entered onto a database and analysed using EPI-INFO. For a subset of questions, answers from responders with similar characteristics to non-responders were compared with those of other responders. Chi-square goodness-of-fit, on two-by-two contingency tables with Yates' correction, was used for all tests of significance.
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Results |
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Accurately completed questionnaires were received from 174 responders (from 68 practices), giving a response of 74% (72% of practices). Responders were different from non-responders; they were more likely to be in partnerships rather than single-handed practices (8% of responders worked single-handed compared with 23% of non-responders, P < 0.01), to be members or fellows of the Royal College of General Practitioners (50 versus 31%, P < 0.05), and more likely to have 10 or fewer years of experience as a GP (45 versus 16%, P < 0.001). Responders with characteristics similar to those of non-responders showed no significant difference, when compared with other responders, in their response to a subset of questions.
Table 1
illustrates GPs' knowledge of the conditions for which there is evidence of a beneficial effect of regular activity. Generally, GP knowledge was good; only a minority of responders indicated that there was evidence associating regular activity with reduced risk of Alzheimer's disease and breast cancer (10 and 14%, respectively). This group of GPs tended to respond positively to all the conditions listed. GPs' knowledge of current recommendations of levels of activity required to achieve health gain was also good. Nearly three-quarters of responders believed that any level of activity was beneficial to health, with less than 10% stating that strenuous or vigorous activity was necessary (Table 2).
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Table 2
details the responses of GPs to a number of attitudinal statements. Over three-quarters of responders believed that they had sufficient knowledge to give advice about physical activity. Most believed that their advice to increase activity was more effective when linked to a patient's presenting problem, and less than one-quarter agreed that they tried to encourage as many patients as possible to increase their activity.
Table 3 contains the responses of GPs to statements regarding the patient conditions for which they would be likely to give advice about physical activity. GPs indicated that they would give advice to patients who were overweight more frequently than they would for any other condition listed. Large numbers also indicated that they would give advice to patients with risk factors for ischaemic heart disease, known ischaemic heart disease, diabetes and hypertension. Only 8% (n = 14) indicated that they would opportunistically give advice to all patients.
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The most frequently identified barriers to promoting activity were lack of consultation time (161, 92.5%), physical activity not being relevant to the consultation (119, 68.4%) and a belief that patients would not follow GP advice to be more active (96, 55.2%).
Discussion
This study indicates that GPs have good levels of knowledge of both the health benefits of regular activity and the levels of activity required to achieve these benefits. The low percentage of responders who indicated that there was evidence of benefit for Alzheimer's and breast cancer tended to have a ‘set response’ for all conditions, suggesting that the results for other conditions may be exaggerated by this small amount.
These findings contrast with other work that has found primary care workers' knowledge of the specific health gains from physical activity to be poor and sketchy.13,14 Some of this work14 looked at the knowledge of health professionals using a specific exercise on a prescription scheme, and the results are likely to have been influenced by the clinical referral criteria used in the scheme. Work by Gould et al.13 was published 3 years ago, and it is possible that the results of our study illustrate an increase in knowledge since then. Knowledge may have increased through information sent to all GPs from the Health Education Authority7 and Health of the Nation Task Force.8
This study suggests that GPs believe advice to increase physical activity is most effective when linked to the presenting complaint, and this belief is reflected in self-reported practice. This approach has been shown to be effective in disease prevention in individuals at high risk, and the conditions that GPs, in this study, indicate they target are appropriate for this individual benefit.15,16 However, promoting behaviour change in high-risk individuals will do little to reduce the burden of ill health in the population.
A systematic review of the effectiveness of promoting lifestyle change in general practice found some evidence to suggest a small but important population effect of GP advice to increase activity.17 A systematic review of interventions aimed at increasing activity in healthy free-living individuals found that promoting activity which was home-based, involved unsupervised informal activity of a moderate intensity and in particular included walking produced successful outcomes in terms of sustained increases in activity.12 It has been suggested that promoting activity of this nature could easily be done in UK primary care and could have an effect on the population level of activity.18
Our study suggests that, in practice, very few GPs promote physical activity in a way that would influence behaviour at the population level. This is in keeping with the findings from GPs in New Zealand and Australia.19,20 Even in the area of smoking, where evidence for the efficacy of GP advice is strong,10 GPs do not seem to practice in a way which would influence behaviour at the population level.21
Time, lack of relevance to the consultation and concerns that patients were unlikely to follow advice were identified as the most important barriers to promoting activity. Time has been shown to be an important reason for not undertaking more health promotion activity in a number of studies.19,20,22 In addition GPs' attitudes towards promoting physical activity are likely to have been influenced by ‘exercise on prescription schemes’, which are now widespread, but which adopt a high-risk approach and do not have a population impact.6
The new Green paper "Our healthier nation" marks an important change in its acceptance that health of a population is determined by factors largely outside of medical services.23 Though health professionals have a role, the green paper makes it clear that to affect the population's health, radical changes are required involving a number of agencies working together to tackle social, environmental and individual factors. Indeed, the white paper "The New NHS: Modern, Dependable" stresses the need for all health professionals to be involved in partnerships with other agencies.24 This is a new mode of working, but may provide a means for primary care to be active in population-based health promotion. Work from New Zealand suggests that GPs feel their efforts to increase physical activity would be more effective if they were supported by wider measures involving other agencies such as the media and schools.19
This study is further evidence that the potential for GPs to affect the health of the population is not achieved in practice. Results from this study suggest this is not owing to a lack of knowledge, but probably reflects the working practices of GPs. The ‘New NHS’ may offer different opportunities for a primary care role in population health.
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Acknowledgments |
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We should like to thank Professor Rhys Williams, Nuffield Institute for Health Leeds, Dr Sheila Webb, Consultant in Public Health Medicine Bradford Health Authority, and Dr Maggie Eisner, GP in Bradford, for their advice and help in the development of this study. We should also like to thank all those GPs who kindly participated in the pilot and final study.
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References |
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1 Fentem PH. Benefits of exercise in health and disease. Br Med J 1994; 308: 1291–1295.
2 Royal College of Physicians. Medical Aspects of Exercise: Benefits and Risks. London: Royal College of Physicians, 1992.
3 Morris J. Exercise in the prevention of coronary heart disease: today's best buy in public health. Med Sci Sports Exercise 1994; 26: 807–814.[ISI][Medline]
4 Allied Dunbar/Health Education Authority/Sports Council. Allied Dunbar National Fitness Survey. London: Health Education Authority, 1992.
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6 Fox K, Biddle S, Edmunds L, Bowler I, Killoran AL. Physical activity promotion through primary health care in England. Br J Gen Pract 1997; 47: 367–369.[ISI][Medline]
7 Health Education Authority. Promoting Physical Activity in Primary Care—Guidance for the Primary Health Care Team. London: Health Education Authority, 1996.
8 Physical Activity Task Force. More People, More Active, More Often. Physical Activity in England. London: Department of Health, 1995.
9 Office of Population Censuses and Surveys. General Household Survey. London: HMSO, 1991.
10 Law A, Tang JL. An analysis of the effectiveness of interventions intended to stop people smoking. Arch Int Med 1995; 155: 1933–1941.[Abstract]
11 Russell MA, Wilson C, Taylor C et al. Effect of general practitioners' advice against smoking. Br Med J 1979; 2: 231–235.
12 Hillsden M, Thorogood M. A systematic review of physical activity promotion strategies. Br J Sport Med 1996; 30: 84–89.[Abstract]
13 Gould MM, Thorogood M, Illife S, Morris JN. Promoting physical activity in primary care: measuring the knowledge gap. Health Educ J 1995; 54: 304–311.
14 Smith PA, Gould MM, See Tai S, Illife S. Exercise as a therapy? Results from group interviews with general practice teams involved in an inner-London ‘prescription for exercise’ scheme. Health Educ J 1996; 55: 439–446.
15 NHS Centre for Reviews and Dissemination, University of York. The prevention and treatment of Obesity. Effective Health Care 1997; 3(2).
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Wonderling D, Langham S, Buxton M, Normand C, McDermot C. What can be concluded from the Oxcheck and British Family Heart studies: commentary on cost effectiveness analysis. Br Med J 1996; 312: 1269–1273.
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Ashenden R, Silagy C, Weller D. A systematic review of the effectiveness of promoting lifestyle change in general practice. Fam Pract 1997; 14: 160–176.
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20 Bull FC, Schipper EC, Jamrozik K, Blanksby BA. Beliefs and behaviours of GPs regarding promotion of physical activity. Aust J Public Health 1995; 19: 300–304.[ISI][Medline]
21 Coleman T, Wilson A. Anti-smoking advice in general practice consultations: general practitioners' attitudes, reported practice and perceived problems. Br J Gen Pract 1996; 46: 87–91.[ISI][Medline]
22 Coulter A, Scholfield T. Prevention in general practice: the views of doctors in the Oxford region. Br J Gen Pract 1991; 41: 140–143.[ISI][Medline]
23 Department of Health. Our Healthier Nation. A Contract for Health. A Consultation Paper. London: Presented to Parliament by the Secretary of State for Health, February 1998.
24 Department of Health. The New NHS Modern, Dependable. London: Department of Health, 1998.
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